
Class. 
Book. 



COPYRIGHT DEPOSIT 



THE PRINCIPLES OF 
THERAPEUTICS 



BY 

OLIVER T, OSBORNE, M.A., M.D. 

Professor of Therapeutics, Department of Medicine, 
Yale University 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1921 




,ol 



(D* 



COPYEIGHT, 1921, BY *W. B. SAUNDERS COMPANY 



THE USE IN THIS VOLUME OF CERTAIN PORTIONS OF THE 
TEXT OF THE UNITED STATES PHARMACOPOEIA IS BY VIRTUE 
OF PERMISSION RECEIVED FROM THE BOARD OF TRUSTEES 
OF THE UNITED STATES PHARM AC OPOEIAL CONVENTION. THE 
SAID BOARD OF TRUSTEES IS NOT RESPONSIBLE FOR ANY 
INACCURACY OF QUOTATION NOR FOR ANY ERRORS IN THE 
STATEMENT OF QUANTITIES OR PERCENTAGE STRENGTHS. 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



MAY 14 1921 
©CU617016 




PREFACE 



This book has been written with the one viewpoint constantly 
in mind, namely, to present the data necessary for the advanced 
student to well understand the objects of scientific treatment, 
the rational use of active drugs, and the physical methods used 
in the treatment of disease. It is also aimed to present even 
under-graduate subjects tersely and concisely, so that the practi- 
tioner may well find the book of value as a review of up-to-date 
practical therapy. 

A brief section on prescription writing is offered, a commen- 
tary on the valuable drugs and preparations of the United 
States Pharmacopoeia is presented, a therapeutic classification 
of drugs, and a description of their action and uses are given in 
some detail. Foods and organotherapy are carefully discussed. 
The various physical methods of treatment, electricity, mas- 
sage, exercise, climate, and medicinal springs are described. 
Special treatments for acute and chronic poisoning by drugs, 
and the treatment for most emergencies are. outlined. Rational 
treatments for simple external disturbances are suggested, 
practical advice concerning equipment and preparedness is 
given the young practitioner, the National drug laws are 
described, reportable contagious diseases are listed, and, finally, 
a chapter on Medical Ethics completes the book. 

The author wishes to record his sincere appreciation for the 
help and advice given him by Professor Lafayette B. Mendel 
in the preparation of the section on foods and especially of the 
chapter on vitamines. 

The index has been carefully prepared, and it is hoped that 
both for study and for reference the book will be found of 
value. 

Oliver T. Osborne. 
New Haven, Conn., 
April, 192 1. 

5 



CONTENTS 



PART I 
THE ART OF WRITING PRESCRIPTIONS 

Page 

Introduction 17 

Official Drugs and Preparations 21 

United States Pharmacopceia 22 

Preparations of the United States Pharmacopoeia 22 

Latin in Prescription Writing 25 

Weights and Measures 26 

The Decimal System 27 

The Old System 28 

Table of Equivalents . 29 

Method of Writing Prescriptions 29 

Abbreviations 32 

Prescriptions 33 

Incompatibility . 36 

Dosage 37 

Conditions Modifying the Action of a Drug 40 

Cumulative Effects of Drugs 42 

Drugs That Cause Eruptions 43 

Drugs that Change the Color of the Urine and Feces 44 

Methods of Administering Drugs 44 



PART II 

THE VALUABLE DRUGS AND PREPARATIONS OF THE 

UNITED STATES PHARMACOPCEIA WITH 

COMMENTS 

United States Pharmacopceial Drugs and Preparations ..... 46 
Synonyms 101 

7 



8 CONTENTS 

PART III 

A THERAPEUTIC CLASSIFICATION OF USEFUL DRUGS 

AND A DESCRIPTION OF THEIR ACTION, USES 

AND ADMINISTRATION 

Page 

Drugs Used to Destroy Microorganisms IIO 

Disinfection no 

Antiseptics 116 

Sterilization 119 

Parasiticides 125 

Drugs Used Externally for Action on the Skin 125 

Dusting Powders 126 

Emollients 128 

Counterirritation 132 

Escharotics 138 

Drugs Used For Action on Mucous Membranes 140 

Demulcents 141 

Astringents 141 

Drugs Used for Local Action in the Stomach 148 

Drugs Used to Increase the Appetite 148 

Digestants 150 

Antacids 152 

Drugs Used to Relieve Irritation in the Stomach 153 

Emetics 156 

Drugs Used for Local Action in the Intestinal Canal 157 

Carminatives 157 

Cathartics 158 

Laxatives 161 

Purgatives 166 

Saline Purgatives 168 

Irritant Purgatives 171 

Drugs Used to Diminish Intestinal Putrefaction 1 73 

Anthelmintics 175 

Drugs Administered Internally for Their Action on the Skin . . . . 183 

Drugs Used to Stimulate the Activity of the Skin 183 

Diaphoretics 183 

Drugs Used to Decrease Perspiration 186 

Drugs Used For Their Action on the Genitourinary System 187 

Drugs Used to Increase the Amount of Urine 188 

Drugs Used to Render the Urine Alkaline 190 

Drugs Used to Render the Urine Acid 192 

Drugs Used to Prevent the Growth of Bacteria in Kidneys and Bladder . 193 

Drugs Used to Stimulate the Mucous Membranes 195 

Emmenagogues 195 

Oxytocics 196 

Drugs Used for Action on the Respiratory Tract 198 

Drugs Used to Increase the Secretion of the Mucous Membranes. . . 201 

Expectorants 201 



CONTENTS 9 

Page 
Drugs Used to Decrease the Secretion of the Mucous Membranes . . . 205 
Drugs Used to Relax Spasm 206 

Drugs Used for Action on the Circulation 207 

Drugs Used to Accelerate the Heart 211 

Drugs Used to Depress the Heart 212 

Drugs Used to Strengthen the Heart 214 

Drugs Used to Contract the Blood-vessels: Vasoconstrictors 231 

Drugs Used to Dilate the Blood-vessels: Vasodilators 235 

Drugs Used for Action on the Central Nervous System 247 

Drugs Used to Stimulate the Brain and Spinal Cord 248 

Drugs Used to Depress the Brain and Spinal Cord 257 

Drugs Used to Stop Pain 259 

Drugs Used to Cause Sleep: Hypnotics 270 

Drugs Used to Cause General Anesthesia: Anesthetics 284 

Drugs Used to Cause Local Anesthesia 316 

Drugs Used to Lower the Temperature of the Body 325 

Antipyretics 325 

Drugs and Preparations that are Specific 338 

Prevention and Treatment of Syphilis 343 

The Specific Treatment of Tetany 352 

The Specific Treatment of Malarial Fevers 362 

Serums as Specifics in Hemorrhage ■ . . 369 

Drugs Used as Specifics 371 

Colchicum in the Treatment of Gout 371 

Salicylic Acid in the Treatment of Rheumatism 375 

Drugs Used to Modify Metabolism 382 

Arsenic 382 

To Stimulate Metabolism 388 

Iodine 389 

Iron 394 

Treatment of Anemia 397 

To Increase Uric Acid Excretion 398 

Phenylcinchoninic Acid 398 



PART IV 

THE ENDOCRINE GLANDS AND ORGANOTHERAPY 

General Conslderations 399 

Insanity 403 

Vasomotor Disturbances 405 

Endocrine Glands That Have Positive Therapeutic Value .... 406 

Thyroid Gland 406 

Hypersecretion 420 

Treatment of Graves' Disease 426 

Hyposecretion 430 

Parathyroid Glands 440 



10 CONTENTS 

Page 

Pituitary Gland 445 

Hypersecretion. 450 

Hyposecretion . 452 

Suprarenal Glands 458 

Hyperadrenalism 461 

Hypoadrenalism 463 

Corpus Luteum 473 

Ovaries 478 

Placenta 485 

Mammary Glands 485 

Testicles 489 

Prostate Gland '. 492 

Thymus Gland 493 

Pineal Gland 500 

Pancreas 504 

Secretin 506 

Spleen . . . . , 507 

Liver 507 

Kidneys 508 

Parotid Glands 508 

Brain 509 

Nuclein. . . 510 

Lymph Glands 511 

Bone Marrow 511 

Meat Extracts 511 



PART V 
PRACTICAL THERAPEUTIC MEASURES 

Inhalation 513 

Atomization 517 

Insufflation 518 

Nasal Douching 519 

Gargling 520 

Gavage 524 

Gastric Lavage. 524 

Enemata 526 

Enteroclysis 527 

Urethral Injections 529 

Bladder Irrigations 531 

Vaginal Irrigations 532 

Intra-uterine Irrigation 533 

Hypodermic Medication 533 

Aspiration 535 

Wet Copping 537 

Leeching 537 



CONTENTS II 

Page 

Venesection 538 

Intravenous Injection of Saline Solutions 540 

Hypodermoclysis 542 

Enteroclysis , 543 

Transfusion of Blood 543 



PART VI 

VACCINES AND SERUMS 

Immunity ■ 547 

Allergy 550 

Protein Poisoning — Anaphylaxis 553 

Vaccines . . 555 

Protective and Curative Vaccines 557 

Prevention of Small-Pox 557 

Prevention of Typhoid and Paratyphoid Fevers 559 

Prevention and Treatment of Whooping-cough 560 

Prevention and Treatment of Hay Fever 561 

Test and Treatment of Tuberculosis 561 

Treatment of Gonorrhea 563 

Treatment of Boils and Carbuncles 563 

Prevention of Rabies 564 

Protective and Curative Serums 564 

Antitoxins 564 

Prevention and Treatment of Diphtheria 566 

Schick Test 566 

Prevention and Treatment of Tetanus 568 

Treatment of Pneumonia 568 

Treatment of Bacillary Dysentery 569 

Lumbar Puncture 569 

Treatment of Cerebrospinal Meningitis 573 

Treatment of Anterior Poliomyelitis 574 

Treatment of Chorea 574 



PART VII 

FOODS AND DIETS 

General Discussion 576 

Proteins 578 

Vitamines 582 

PURINS 586 

Milk 587 

Cheese 590 



1 2 CONTENTS 

Page 

Eggs 590 

Nuts 591 

Carbohydrates 591 

Sug.ar 593 

Alcohol 595 

Fats 59 6 

Salts 599 

Water 601 

Fruits 602 

Coffee and Tea 603 

Nutrient Enemata 605 

General Diet Considerations 607 

Diets 611 

Indigestion 612 

Constipation 613 

Gastric Hyperacidity 615 

Intestinal Bacteria 616 

Diet in Fever 619 

Diet in Anemia 621 

Diet in Heart Disease 622 

Salt-Free Diet 622 

Diet in Hypertension 623 

Diet in Pregnancy 623 

Diet in Tuberculosis 624 

Diet in Diabetes Mellitus 624 

Diet in Obesity 627 

Relation of Scurvy to Diet 629 

Relation of Rickets to Diet 630 

Relation of Beriberi to Diet 630 

Relation of Pellagra to Diet 631 

Relation of Xerophthalmia to Diet 631 



PART VIII 
GENERAL PHYSICAL MEASURES 

Hyperemic Treatment 632 

Heliotherapy 634 

Electricity 638 

Galvanism 640 

Cataphoresis 643 

Electrolysis 644 

Faradism 644 

Sinusoidal Current 645 

High Frequency Currents 646 

Diathermy 647 



CONTENTS 13 

Page 

Static Electricity 648 

Roentgen Ray 649 

Radiotherapy 650 

Radio-active Substances 652 

Radium 654 

Hydrotherapy 656 

Massage 673 

Physical Exercise 680 

Rest Cure 690 

Climate 698 

Mineral Springs 706 



PART IX 
CHRONIC DRUG POISONING 

Alcohol 711 

Delirium Tremens 71: 

Morphine Habit 716 

Heroin 718 

Cocaine Addiction 722 

Regulated Treatment or Drug Addicts 723 

Tobacco Habit 725 



PART X 
INDUSTRIAL POISONING 

Lead Poisoning 732 

Poisoning from Paints . 737 

Brass and Zinc Poisoning 738 

Phosphorus Poisoning 738 

Poisoning from Dye-stuffs 740 

Trinitrotoluene Poisoning 741 



PART XI 
TREATMENT OF EMERGENCIES 

Sudden Death 743 

Coma 743 

Illuminating Gas (Carbon Monoxide) Poisoning 745 

War Gas Poisoning 748 



14 CONTENTS 

Page 

Caisson Disease 750 

Drowning 751 

Burns 753 

Treatment of Acute Poisoning by Drugs 757 

Corrosive Sublimate (Mercuric Chloride) Poisoning 761 

Wood Alcohol (Methyl Alcohol) Poisoning 764 

Botulism 766 

Toadstool (Muscarine) Poisoning 768 

Convulsions of Young Children 768 

Sunstroke — Insolation 771 

Heat Prostration — Heat Stroke 773 

Freezing • • 773 

Seasickness 774 



PART XII 

TREATMENT OF SIMPLE DISTURBANCES OF THE 
SURFACE OF THE BODY 

The Relation of the Skin to the Systemic Condition 776 

Itching — Pruritus 777 

Pruritus Vulv,e 779 

Urticaria 780 

Mosquito Bites . . * 780 

Ivy Poisoning 781 

Primrose Poisoning. 782 

Eczema 782 

Chapped Hands 783 

Chilblains 784 

Acne 785 

Impetigo Contagiosa 786 

Sty — Hordeolum 786 

Boils 787 

Carbuncles 788 

Psoriasis 789 

Ringworm — Tinea Trichophytina 790 

Tinea Cruris 791 

Itch — Scabies. . . 791 

Head Lice — Pediculosis 793 

Hygiene of the Hair 794 

Warts 795 

Sweating of the Feet and Axilla — Localized Hyperldrosis 796 

Ingrowing Toe-nail 797 

Inflammation of the Middle Ear — Otitis Media 797 

Leucorrhea 799 



CONTENTS IS 

PART XIII 
PRACTICAL ADVICE TO YOUNG PHYSICIANS 

Page 

Some Truths About Drugs / 800 

Drug Aphorisms 803 

Drug Fallacies 805 

Thermometry Equivalents 806 

Clinical Histories 807 

Therapeutic Chart 809 

The Hypodermic Case 810 

The Pocket Medicine Case 810 

The Always-ready Handbag 810 

Drugs for Office Dispensing 812 

Life Extension 812 

PART XIV 

MEDICAL LAWS AND DEPARTMENTS OF HEALTH 

The Harrison Narcotic Law 815 

The Prohibition Law 815 

Reportable Diseases 817 

State Department of Health 818 

PART XV 

MEDICAL ETHICS 

Principles of Medical Ethics of the American Medical Association . 819 

The Oath of Hippocrates 830 

Ethical Suggestions to the Young Practitioner 831 

Index 837 



THE PRINCIPLES OF THERAPEUTICS 

PART I 

THE ART OF WRITING PRESCRIPTIONS 

INTRODUCTION 

Until recent years therapy was the most studied branch of 
medicine. It was first surrounded by mysticism of all kinds, 
but embodied, even in earlier times, management as well as 
the actual giving of drugs. All good results, however, were 
accredited to the ingested or applied remedy, and, like the 
"lack of sufficient faith" plea of the Christian Scientists for 
their unsuccessful cases, failure to cure in these times was 
ascribed to the special devil or special devil ishness of the 
disease. After this period of amulets, talismans, and elaborate 
mixtures of almost everything available, and the wonderful 
panaceas and cures by all kinds of mental impression, came the 
chemical age, then the age of wonderful cures by multitudi- 
nous dilutions of nothing, and its wonderful success on the mind, 
next came Magendie, the Nestor of physiologic investigation of 
drugs, and finally more scientific medication. 

Rational therapy is the hardest of the practical subjects to 
master, and it is safe to say that the young physician, even 
after a hospital course, is less prepared in the bedside manage- 
ment and the office treatment of disease than in any other 
branch of medicine. In hospital and dispensary cases the treat- 
ment necessarily is much restricted to general routine and to 
formulary preparations; the patient is not individualized, and 
other therapeutic measures are not often available, especially 
in dispensary cases. Students rarely learn in this manner fine 
individualized scientific therapy for private practice. In the 
hospital, the diet, bathing, electricity, massage, drugs and 
preparations are always given and used according to some one 

2 17 



iS THE PRINCIPLES OF THERAPEUTICS 

rule which can not well be varied in these institutions to suit 
an individual taste or need. Hence the graduate, and even the 
post-graduate, unless he has especially studied therapy, starts 
his individual practice of medicine positively handicapped. 
He has no resources if his first dogmatic treatment has failed 
or has not been suited to the patient. 

Each and every clinician well knows that it is only the con- 
sultant who can ignore the treatment of troublesome symptoms. 
All successful quackeries succeed . because of their ability to 
relieve symptoms or to cause such mental suggestion as will 
relieve overtaxed minds, and many a loyal patient is driven to 
employ quackery by scientific neglect. 

The physician must carefully study his patients, their 
symptoms, and the result of his treatment, and especially the 
results of medication. He must never confound his patient 
with the disease; it is the patient who has the disease that he is 
called upon to treat. Hence the therapist must individualize 
the man, woman or child who comes to him for treatment. 

Fred Shattuck, of Boston, once said, "The surgeon's knife 
is in reality a confession of failure in so far as it is used for the 
relief of pathological surgery." We should go a step farther 
and still call it therapy when the physician decides that opera- 
tive intervention is needed and is advisable. But the internist 
should not wholly release his patient to the operating surgeon, 
but should control and manage his pre-operative, post-opera- 
tive, and convalescent periods with, of course, consultation 
with the surgeon. Surgeons are often not alert to physiologic 
disturbances in their operated cases, and hence do not properly 
manage such disturbances, and many a surgical patient gets 
well in spite of the post-operative treatment rather than on 
account of it. Also, the operated patient is often a "case" to 
the skilled, busy operator; but it is a fact that proper medical 
care after the operation will very many times prevent long, 
tedious convalescence, and may even prevent permanent 
invalidism. 

We hear of natural born physicians, of intuitive sense, and 
of great success in medicine without much medical education, 
and often without even accurate diagnoses. This is true; a very 



THE ART OF WRITING PRESCRIPTIONS 19 

scientific practitioner may fail at the bedside, while a man with 
broad, keen, intuitive sense will succeed. " Common sense" 
as it has been termed, or slangly "horse sense," is that ability 
to visualize all the knowledge applicable to the given case and 
then to note all of the individualities of the patient and to 
modify the treatment accordingly. 

In spite of all diagnostic acumen and diagnostic measures, 
many a patient gets well without a diagnosis, and some die with 
negative autopsy findings. 

Good therapy is an art. It requires high training, stored 
knowledge, and good judgment to decide the proper hygiene, 
diet, exercise, rest, eliminative or antidotal treatment, and the 
physical measures, drugs, or surgery needed to cure a given 
patient. It also requires good judgment to decide that a 
patient needs only psychic treatment. Also, after the diagnosis 
is made, no two patients can be successfully treated in exactly 
the same way. 

We have not sufficiently studied the various "pathies" and 
appropriated to our own use the modicum of value which each 
may possess. 

Unfortunately for the determination of what is rational and 
scientific therapy, we cannot dissociate ourselves from a deeply 
imbeded belief in mystery in the treatment and cure of disease, 
hence mankind, and the physician is no exception, is impressed 
by cures by physical methods and by multiple or secret mix- 
tures, when the cure is really caused by mental impression. 

A cure for a great evil to-day would be to compel every mental 
healer, Christian scientist, osteopath, chiropractor, or pseudo- 
practitioner of any other fraud or cult, to pass an examination 
in pathology and bacteriology. No one of these people, unless 
he were a rascal and subject to prosecution for trifling with 
human life, could study gross and microscopical pathology and 
bacteriology, and then make grossly absurd statements to their 
patients and to the public as to the cause and method of cure of 
disease, or could promise to cure incurable diseases. Also they 
would not use methods of treatment that either neglect or 
aggravate a diseased condition. 

The old hobby of letting Nature cure the patient has been 



20 THE PRINCIPLES OF THERAPEUTICS 

ridden too long. Nature is a good mother, but she will do just 
as much to propagate a pathologic germ as she will do to pro- 
mote the welfare of the human being infected by that germ. 
Consequently, neglect will not cure a patient. On the other 
hand, because a patient has an incurable disease, or has a disease 
for which there is no specific treatment, is no excuse for neglect- 
ing every other discomfort that he may be enduring. Neither 
should a complaining individual be neglected because we find 
nothing the matter with him as far as we with our limitations 
can determine. Such an individual needs mental, moral, or 
physical aid of some kind. 

Besides all sanitary and hygienic advice, providing proper 
nourishment for the baby, advice for the proper management 
of the child, and protective vaccinations and serum treatment, 
there still remains a large field for the proper use of proper 
drugs, given in a proper manner, not only to prevent the 
progress of disease, but to improve the physiology, to correct 
and aid elimination, and to modify the various disturbances to 
which human flesh is heir. 

We have not yet eliminated mystery from medical practice, 
and still have a belief, unless we very carefully eliminate it, in 
a multiple mixture, although it may not be a mythical mixture, 
we may know its contents. It is so easy to believe when we are 
told that a drug in this particular combination has a particularly 
pleasant and efficient activity, or that this particular kind of 
a drug or preparation will not cause the disturbance that the 
well-known and well-tried basic drug causes. 

We rarely need mixtures, whether Pharmacopceial, National 
Formulary, or proprietary. Such mixtures may have value, 
but the active drug of the mixture can generally be given in a 
very simple manner and the results obtained be perfectly 
satisfactory, and the treatment be much more scientific. 

A part of good therapy consists in the right use of the right 
preparation of the right drug. This object can only be obtained 
by a knowledge of the pharmacologic and toxic action of the best 
drugs, by a knowledge of their best preparations, and by a 
knowledge of how to administer them in proper doses. Con- 
sequently, Part I of this book aims to briefly teach good pre- 



THE ART OP WRITING PRESCRIPTIONS 21 

scription writing, Part II is devoted to comments on the best 
drugs and preparations of the Pharmacopoeia, and Part III is 
devoted to a description of the activities, uses, and the best 
methods of administration of the valuable drugs. 

OFFICIAL DRUGS AND PREPARATIONS 

The National Pure Food and Drug Law recognizes the United 
States Pharmacopoeia and the National Formulary as standards 
for drugs, their preparations and their doses. 

The Ninth Revision of the United States Pharmacopoeia is 
the last volume issued of this book, and is naturally the best 
ever issued, but owing to commercial desire and to the desire 
of Government drug officials for standards for everything used 
in medicine, whether medicinally useful or not, and also from the 
desire of many physicians who wish a supposed standard for 
drugs and preparations that have no action and cannot be 
standardized, the book is altogether too large and contains 
too many drugs and preparations for an up-to-date physician, 
who wishes standards of only the best drugs. 

The National Formulary is a book primarily produced to offer 
certified formulas for many really useful proprietary mixtures, 
so that any druggist could reproduce these preparations. It 
consists largely of multiple mixtures (mostly out of date) and of 
mixtures left over from the United States Pharmacopoeia after 
house-cleaning. 

The contention of the United States Bureau of Chemistry 
that a standard was needed for all drugs, whether useful or not, 
in the last revision" of the United States Pharmacopoeia was not 
valid, as a standard can always be found in the volume of the 
United States Pharmacopoeia in which the drug was last 
mentioned. 

It is always best to individualize a patient and to write a 
prescription for one or more drugs especially for him. How- 
ever, many Pharmacopoeial, some National Formulary, and 
some proprietary mixtures are elegant methods of combining 
or administering drugs, and in proper cases should be used. 
A valuable useful book is entitled "New and Nonofficial 
Remedies." This book is revised and published annually by 



2 2 THE PRINCIPLES OF THERAPEUTICS 

the American Medical Association. It describes all new 
drugs and preparations that are found to be as represented 
and that are not advertised to "cure" or "guaranteed to help," 
but that really have good therapeutic uses. 

UNITED STATES PHARMACOPOEIA 

The first National Pharmacopoeia of the United States was 
developed by a convention which met in Washington, in 
1820. The second edition appeared in 1828, and from 1830 
there have been decennial conventions of representatives from 
the professions of medicine and pharmacy, with delegates 
from state medical societies, medical and pharmaceutical 
colleges, and from the army, navy and marine hospital service 
of the United States. At these conventions, held in Washing- 
ton, are appointed revision committees whose labors develop 
the decennial editions of the Pharmacopoeia. 

The last, now official, is the ninth revision, and the one 
representing the standard from which the physician's pre- 
scription will be filled, unless he otherwise orders. This 
ninth revision was prepared by a committee of fifty, appointed 
by the delegates at the convention held in Washington in 1910. 
This book did not appear or become standard until 191 6, and 
will be standard until the tenth revision appears some years 
subsequent to the meeting of the Pharmacopceial Convention, 
which was held in Washington, in May, 1920. 

This book contains 778 drugs, substances and preparations, 
very, very many of which are of no value to the modern practi- 
tioner. 

The drugs and preparations appear alphabetically under 
their Latin and English titles. The average doses are given in 
both the metric and the apothecaries systems. The United 
States Pharmacopoeia has for three revisions urged the use of 
the metric or decimal system, but only a small minority of the 
physicians of the United States have adopted this system of 
weights and measures. 

A drug or preparation described in the United States Phar- 
macopoeia is termed "official." The ninth revision of this 
book recognizes the following types of preparations: 



THE ART OF WRITING PRESCRIPTIONS 23 

Aceta (Vinegars) are solutions of the active principles of 
drugs in dilute acetic acid. One is official. 

Aquae (Waters) are solutions of volatile substances in water. 
Seventeen are official. 

Cerata (Cerates) are semisolid preparations made with 30 
per cent, of white wax and 70 per cent, of benzoinated lard. 
They do not melt when applied to the skin. Four are 
official. 

Collodia (Collodions) are liquid preparations for external 
use having collodion as a base. Three are official. 

Decocta (Decoctions) are liquid preparations made by boiling 
vegetable substances in water. Unless otherwise ordered, 
decoctions are made to represent 5 per cent, strength of the drug. 
None is official. 

Elixira (Elixirs )are sweet, aromatic, alcoholic preparations 
containing small amounts of medicinal substances. Two are 
official. 

Emplastra (Plasters) are preparations for application to the 
skin and are adhesive at the body temperature. Seven are 
official. 

Emulsa (Emulsions) are liquid preparations in which oily sub- 
stances are suspended in water by the aid of a gummy or albumi- 
nous substance. Four are official. 

Extracta (Extracts) are solid, semisolid, or dry fine powders 
intended mostly for internal medication. Twenty-five semisolid 
and two powdered extracts are official. 

Fluidextracta (Fluidextracts) are concentrated liquid pre- 
parations made of such strength that 1 mil (cubic centimeter) 
represents the medicinal properties of 1 gram of the drug. 
Forty-nine are official. 

Glycerita (Glycerites) are mixtures of medicinal substances 
with glycerin. Five are official. 

Infusa (Infusions) are weak liquid preparations made by 
treating a drug with hot water but not boiling the mixture. 
Unless otherwise ordered, they represent 5 per cent, strength of 
the drug. Two are official. 

Linimenta (Liniments) are mostly liquid preparations for 
-external use. Eight are official. 



24 THE PRINCIPLES OF THERAPEUTICS 

Liquores (Liquors) are solutions of non-volatile substances 
in water. Twenty-five are official. 

Massas (Masses) are semisolid preparations of the consis- 
tency to roll into pills. Two are official. 

Mella (Honeys) are thick liquid preparations with honey as a 
base. Three are official. 

Misturae (Mixtures) are liquid preparations containing sub- 
stances held in suspension in water. Two are official. 

Mucilagines (Mucilages) are solutions of gum in water, used 
as demulcents or to suspend insoluble substances or oils in 
mixtures. Two are official. 

Oleata (Oleates) are combinations of medicinal substances 
with oleic acid. One is official. 

Oleoresinae (Oleoresins) are extracts containing a volatile 
oil and a resin. Six are official. 

Olea (Oils) are either volatile or fixed. Thirty -eight are 
official. 

Pilulae (Pills) are small round solid preparations of drugs 
for internal administration. Seven are official. 

Pulveres (Powders) are finely powdered preparations of two 
or more drugs. Seven are official. 

Resinae (Resins) are solid preparations. Three are official . 

Spiritus (Spirits) are strong solutions of volatile substances 
in alcohol. Fifteen are official. 

Suppositoria (Suppositories) are medicated preparations for 
insertion into the different orifices of the body. The vehicles 
used in their preparation are cacao butter, glycerinated gelatin, 
or sodium stearate. A suppository for the rectum should weigh 
about 2 grams; a suppository, or bougie, for the urethra should 
weigh from 2 to 4 grams ; and a vaginal suppository should weigh 
from 4 to 10 grams. One is official. 

Syrupi (Syrups) are concentrated solutions of sugar in 
water medicated with one or more drugs. Twenty-two are 
official. 

Tincturae (Tinctures) are solutions of non- volatile substances 
in alcohol. 100 mils of a tincture of a potent drug should 
represent 10 grams of the drug. Tinctures of weaker, non- 
potent drugs vary in strength. Fifty-four are official. 



THE ART OF WRITING PRESCRIPTIONS 25 

Triturationes (Triturates) are solid preparations made with 
sugar of milk. One is official. 

Trochisci (Troches) are medicated lozenges for solution in the 
mouth. Five are official. 

Unguenta (Ointments) are semisolid preparations made with 
20 per cent, of white wax and 80 per cent, of benzoinated lard. 
Twenty are official. 

LATIN 

There has been a slowly progressive change from prescriptions 
written entirely in correct Latin, to abbreviated Latin, to 
part Latin and part English, to incorrect Latin and abbreviated 
English, until now it seems advisable to advocate that the whole 
prescription be written in good English with the use of the 
abbreviations of the Latin titles of drugs as authorized by the 
United States Pharmacopoeia and the use of such technical 
abbreviations as seem advisable. It would also seem well to 
write the names of the common simple drugs and preparations 
in English rather than in their high sounding mysterious Latin 
titles; for instance, to write peppermint water instead of aqua 
menthce piperita. The patient knows that the taste is that of 
peppermint, hence the camouflage is absurd. 

The decision to advise that prescriptions be written in 
English has been arrived at because Latin is not now an entrance 
requirement in most medical schools, and incorrect Latin is an 
abomination. Also the physician should do his part in com- 
pleting the laying of the ghost of mystery. Education and 
public health instruction have removed much of the mystery 
of disease and, hence, most of the belief in mysterious means 
of prevention and of cure, and the physician should do the 
rest. Most nostrums and most irregular methods for the cure 
of disease thrive only by their appeal to the long inherited 
belief in mystery and magic. Therefore it is urged that we 
inaugurate the plan of writing prescriptions simply, as well as 
writing simple prescriptions. The age of multiple mixtures of 
one or two useful drugs befogged by many useless and unneces- 
sary ingredients is passing. Let the exit of such unscientific 
combinations be hastened. On the other hand, more time 
and thought should be given to determining the most efficient 



26 THE PRINCIPLES OF THERAPEUTICS 

method, and at the same time the pleasantest manner, of 
administering active, useful drugs. 

WEIGHTS AND MEASURES 

It should not be necessary to declare that the metric, decimal, 
system is the best with which to compute prescriptions. The old 
apothecaries system is the only attachment modern medicine 
now has to more or less ancient medicine. Many a physician is 
technically equipped up-to-date in all branches of medicine 
except in that of writing prescriptions. 

The decimal system of prescription writing is universal ex- 
cept in England and the United States. Our monetary system 
is the decimal system, and one has only to think of doses in 
terms of dollars, cents and mills, i.e., in grams, centigrams, and 
milligrams for solids, and mils (cubic centimeters) and fractions 
of mils for liquids, to readily understand this method of 
meaurement. 

Two causes have kept the majority of physicians from adopt- 
ing the decimal system. First, because most books have taught 
exact equivalents of doses in the two systems, namely, a grain 
was .065 grams, and half a grain was .0325 gram, etc., and most 
doses were translated into impossible figures. If a dose is 
learned as .05 gram, for instance, but few would try to translate 
it as 5/6 and a fraction of a grain. When it is recognized that 
the dose of a drug may vary from one to three grains, it should 
also be recognized that the dose of that drug is just as accurately 
expressed as from .05 to .20 gram. 

The second reason that the decimal system has not been 
generally adopted in the United States is because of the inertia 
of hospitals and dispensaries. They will not change their 
stock mixtures, and some of the best hospitals in this country 
have the most ancient formularies. Therefore the young 
graduate in medicine, though he may have been taught the 
decimal system, soon forgets it and learns the old weights and 
measures used in the hospital in which he becomes an interne, 
and this very hospital will accurately describe how many cubic 
centimeters of blood were transfused, how many parts to one 
thousand a given solution of corrosive sublimate contains, and 



THE ART OT WRITING PRESCRIPTIONS 27 

stiJl have nitrate of silver solutions of "so many grains to the 
ounce." Let us hope that the hospitals will purge themselves 
of their ancient formulas and surgically eradicate the old 
apothecaries system of weights and measures. 

The United States Pharmacopoeia gives the average doses in 
both systems but still insists on the accuracy of a fluid drachm 
equalling 4 mils (ex.), which is correct; but the contention 
seems good that any average dose stated as 4 mils would be 
equally accurate, on the average, if it was stated as 5 mils. 
Also the equivalence of one fluid drachm to 4 mils depends upon 
where the meniscus is read. Such accuracy in doses of drugs 
and their preparations, the dose of which is as large as one fluid 
drachm, is refined absurdity. Also, physicians write in the 
apothecaries system for so many fluid ounces and order the 
dose as a teaspoonful, and compute the doses of the active in- 
gredients on a basis of 8 fluid drachms to the ounce, i.e., 8 
teaspoonfuls. The patient most always gets more than a fluid 
drachm (4 mils) at a dose, as most teaspoons readily hold 5 mils 
(5 c.c.). Hence another contention, that most every patient 
given a liquid preparation written in the old system and pre- 
scribed in teaspoonful doses receives more of the active in- 
gredients of the prescription than was intended. The above 
discussion is really almost superfluous, for the dose of any drug 
is enough, and too much at any sized dose is too much. 

To repeat, fine fractional equivalents of doses, though 
chemically correct, are therapeutic nonsense. Every student of 
medicine and every practitioner, who still uses the old system, 
should learn the doses of drugs in the decimal system and 
radically dissociate the two systems : namely, a teaspoonful may 
be considered equal to 5 mils ; 1 gram may be considered equal to 
15 grains; .05 gram may be considered equal to 1 grain; .01 gram 
may be considered equal to }i of a gram ; and .001 gram may be 
considered equal to %o of a grain. 

THE DECIMAL SYSTEM 

The United States Pharmacopoeia directs that solid drugs 
shall be weighed in the decimal system, and that liquid drugs 
and preparations shall be measured in the decimal system. 



28 THE PRINCIPLES OF THERAPEUTICS 

The base of this system is the meter, an established length 
representing one-forty millionth part of the earth's circumfer- 
ence around the poles, and equivalent to 39.370432 inches. The 
unit of volume is the liter, a cube having the length of its side 
equal to }{q of a meter, and equivalent to 2.056716 pints. The 
unit of weight is the gram, the weight of a cube of water at 4°C. 
having the length of its side equal to Jioo of a meter, and 
equivalent to 15.432 grains. A smaller unit of volume is used, 
namely, the cubic centimeter (decreed by the last revision of the 
United States Pharmacopoeia to be termed "mil"). The 
cubic centimeter, or mil, equals Mo 00 of a liter, that is a 
cube having for its side K o of a meter. A larger unit of 
weight is used, namely, the kilogram (1000 grams) which equals 
about 2% pounds. 

Although the United States Pharmacopoeia recognizes deci- 
mils and decigrams, for dosage and prescription writing the 
following fractional terms are sufficient, more simple, and 
accurately agree with the pharmacists' metric weights and 
measures. 

Table for Liquids 
0.0 1 = 1 centimil. 
0.10 = 10 centimils. 
1. = 100 centimils or i mil (i c.c). 
1000. = 1000 mils or 1 liter. 

It should be remembered that i mil is the same as i c.c, and iooo mils as 
1000 c.c. 

Table for Solids 
0.00 1 = 1 milligram. 

0.010 or 0.01 = 10 milligrams, or i centigram 
0.100 or 0.10 = 100 milligrams, or 10 centigrams (or i decigram). 
1 . = 1000 milligrams, or ioo centigrams, or i gram. 
1000. = 1000 grams, or i kilogram (i kilo), 2^4 pounds. 

OLD SYSTEM 

For ready reference the tables of the old system are given; 
the complicated and easily mistaken symbols should be com- 
pared with the clear figures of the decimal system. 

Troy, or Apothecaries, Table 
60 grains (Gr. lx) = 1 drachm (5i). 
8 drachms (Sviii) = 1 ounce (§i). 
12 ounces (gxii) = 1 pound (1 lb.) 



THE ART OF WRITING PRESCRIPTIONS 2 9 

Wine, or Apothecaries, Measure 

60 minims (M lx) = 1 fluid drachm (fl. 50- 
8 fluid drachms (fl. 5viii) = 1 fluid ounce (fl. §i). 
16 fluid ounces (fl. §xvi) = 1 pint (O i). 

For ready reference the following table of approximate equivalents of the two 
systems will be found useful: 

1 grain = approximately 0.065 gram. 

1 minim = approximately 0.065 mils. 

15 grains = approximately 1 gram. 

15 minims = approximately 1 mil. 

1 drachm = approximately 4 grams. 

1 fluid drachm = approximately 4 mils. 

1 ounce = approximately 30 grams. 

1 fluid ounce = approximately 30 mils. 

1 teaspoonful = approximately 5 mils. 

1 pint = approximately 500 mils. 

1 quart = approximately 1000 mils, or 1 liter. 

PRESCRIPTION WRITING 

Even if surgical, special and specific treatments are the only 
correct methods of effecting a cure of disease, and even if 
most acute diseases tend to recovery, and even if correction of 
the diet, hygiene, etc., tends to eradicate abnormal conditions of 
the body, the patient will still require more or less medicinal 
treatment to stop pain, to promote nutrition, to increase 
general elimination, to decrease any abnormally profuse 
eliminative activity, to produce sleep, to supply or aid the 
activity of some internal secreting gland, and to soothe, stimu- 
late, or otherwise treat the external surface of the body. Hence, 
however much the surgeon may state that he does not need 
drugs, and however much the consultant may deplore the use 
of drugs, they must be, and are, used legitimately for the vast 
majority of all patients. 

Nothing in the above statements is intended to declare that 
many chronic conditions, especially of the nervous system, 
are not better treated by physical methods than by drugs, or 
that it is not a fact that too much medicine is often given to 
acutely sick patients. However, the absolutely drugless treat- 
ment of acute and really tangible chronic illness is a myth. 
If there is nothing the matter with an individual, of course he 
can be cured of what he did not have by what he does not get. 



3° 



THE PRINCIPLES OF THERAPEUTICS 



That there are useful drugs and that such drugs have a known 
and demonstrable activity is doubted by no one of sane mind. 
That these drugs can produce the symptoms and signs of their 
action in patients is known by everyone who has had laboratory 
and subsequent clinical experience. These facts should compel 
two restrictions in the use of drugs: (i) a drug should not be 
used that is not known to have some definite, safe activity; 
(2) only one who has the knowledge of the action of a drug on 
the human being in health and in disease should prescribe that 
drug for a patient. 

A self-evident corollary of the above is that a mixture of 
drugs cannot be prepared or "kept in stock" to fit a patient who 
may need treatment some time in the future. Each patient 
should be individualized and should receive the drug needed, 
in the amount necessary to cause the effect desired, and he 
should not receive a mixture of drugs that was made to fit a 
series of patients who will vary in age, size, nutrition, strength, 
and in the severity and complications of their disease, even if 
they have the same disease. Hence proprietary, drug-store, 
hospital, dispensary and office mixtures are unscientific, and 
at times may even be dangerous treatment. 

Many official (U. S. P.) preparations of useful drugs repre- 
sent good methods of administering such drugs, and these 
should be more frequently ordered rather than to have recourse 
to proprietary preparations of no more value, efficiency, or 
elegance. Some of these preparations are kept ready prepared 
in the drug shops, and some are compounded by the pharmacist 
at the time of receiving prescriptions calling for them. In 
either case, the physician expects the preparation to be standard 
and always the same. Some ready-made preparations, and 
especially if in unsealed packages, may deteriorate, and hence 
freshly prepared preparations are, and should be, demanded. 
In spite of the pharmacal elegance and perfection of the prep- 
arations of the United States Pharmacopoeia and National 
Formulary, generally a prescription should be written especially 
individualized for the particular patient. This does not mean 
that a drug must necessarily be combined with something else, or 
that some mixture be ordered by the physician when there 



THE ART OF WRITING PRESCRIPTIONS 3 1 

is almost an exact copy of his combination — only more elegant — 
official in the United States Pharmacopoeia. Hence every 
physician should study the United States Pharmacopoeia, 
and for quick reference the reader is referred to the list of 
useful official drugs and preparations in Part II of this book. 

The aim of prescription writing should be for efficiency 
(activity of an active, useful drug), for simplicity, and for 
compatability. Toward these ends one sees that the prescrip- 
tion writer, the physician, must know which are the useful 
drugs; must have an accurate knowledge of the activities of 
these drugs; must know which one, or more, meets the indica- 
tion it is desired to meet; and must know the best preparation 
of the drug to use, the best combination in which to give it, 
and finally, the best method of administering it. The physician 
must also know the proper dose, the rate of absorption, the 
rate of excretion, and hence the proper frequency of the dose. 
Therefore, before one should write an individual prescription 
for a patient he must be fully trained to practice medicine. 

The physician should always have a copy of his prescriptions, 
and a stub is better than a carbon copy, as on the stub may be 
written the size of each dose, with the name, age, and address of 
the patient, and the date. The main prescription may then be 
(after computing) written, signed and dated. The stub 
then kept becomes a record of the drugs and doses given such a 
patient at a given date. 

The physician should write simple prescriptions of useful 
drugs in the best official preparation, and, if soluble, in the most 
agreeable solution possible. A pharmaceutical firm that offers 
a pleasant preparation of a disagreeable but valuable drug, or 
presents a purer valuable drug, should be commended, and such 
preparations should be used. Also, if a chemical firm offers a 
new synthetic or a purer alkaloidal product of a useful drug, 
and if such have been approved by the Council on Pharmacy 
and Chemistry of the American Medical Association, they 
should be used in suitable cases. 

A large number of elaborate combinations are made and sold 
under different names to cover the taste of simple, useful, but 
disagreeable-to-take drugs. The physician should remember 



32 THE PRINCIPLES OF THERAPEUTICS 

that not always does sweetness make a bad tasting drug 
taste less disagreeable. Many a more or less nauseating drug 
is much better tolerated by dissolving it in a sour mixture, as in 
syrup of citric acid and water. Also, a drug dissolved in simple 
water may be added to fresh lemonade or orangeade. Pepper- 
mint has a very pleasant taste for most people, and as disagree- 
able a drug as potassium chlorate when used as a gargle, may 
be well dissolved in peppermint water. 

Effervescing water, either simple carbonated, or better an 
alkaline water as vichy, is a pleasant method of administering 
many drugs, even insoluble powders; the powder is suspended, 
as bismuth for instance, by the air globules. 

An oil like castor oil, or cod liver oil, may be disguised by 
placing a little salt in the bottom of a wineglass, then filling the 
glass half full with cold water without stirring to dissolve the 
salt, and then placing the oil carefully on top of the water. If 
this mixture is rapidly swallowed the only taste is that of the 
salt. Castor oil is variously disguised by the addition of a 
small amount of saccharin and a little oil of anise or oil of 
wintergreen, and may then be given in orangeade. Or, it may 
be further disguised by adding fluid extract of licorice. 

The disagreeable taste of epsom salt may also be disguised 
by a little saccharin and oil of peppermint or wintergreen. 

A pleasant method of administering many disagreeable drugs 
to children is to give them in a teaspoonful or tablespoonful of 
freshly made cocoa or chocolate. Or, a little sweetened choco- 
late may be crushed by the mother and given with the powder 
or solution. 

Evolution of a Prescription 

While it is advised to write prescriptions as far as possible in 
English, it is also advised to use a few Latin abbreviations, 
The numerals used should always be in Arabic. 

Abbreviations 

aa ana (Greek) of each 

a.c ante cibum before meals 

ad ad up to 

b.i.d bis in die twice a day 

cap capsula a capsule 



A 



THE ART OF WRITING PRESCRIPTIONS 



33 



chart ' chartula 

F fac 

Gm gramma 

M misce 

no in numero 

p.c post cibum 

pil pilula 

p.r.n pro re nata 

q.s quantum sufficit 

Ifc recipe 

S. or Sig signa 

t.i.d ter in die 



Stub 



3 Salt 

Water 

M. 

S. In water, after meals. 



Gm. 
mil 

i . 

5- 



3 

M. 

S. 



a paper 
make 
gram 
mix 

in number 
after meals 
a pill 

when required 
a sufficient quantity- 
take 
mark 
three times a day 

Prescription for io Doses 

Gm. 
mil 

Salt io. 

Water 50. 

A teaspoonful, in water, three 
times a day, after meals. 



Same prescription with U. S. P. names, abbreviated: 

Gm. 
mil 

1^ Sod. chlorid 10 . 

Water 50 . 

M. 

S. A teaspoonful, in water, three times a day, after meals. 

For more than One Ingredient 



M. 

S. 



Stub 

Gm. 
mil 

Sod. chlorid 1. 

Sod. bicarb o . 50 

Syrup 2.50 

Water up to 5 . 

t.i.d., p.c. 



S 



M. 

S. 



Prescription for 10 Doses 

Gm. 
mil 

Sod. chlorid 10. 

Sod. bicarb 5. 

Syrup 25. 

Water q.s. ad 50. 

A teaspoonful, in water, three 
times a day, after meals. 



Prescription for an Official Pill 
Stub 



fy Pil. ferr. carb. 
S. t.i.d., p.c. 



Prescription 
1$ Pil. ferr. carb. No. 20 
S. One three times a day, after meals. 



A pill should rarely contain more than 0.30 gram, and a 0.20 gram pill is 
better. In other words, a pill should not be large. 
3 



34 THE PRINCIPLES OF THERAPEUTICS 



Prescription for a Pill with Several Ingredients 

Stub Prescription for 20 Doses 

Gm. Gm. 

mil mil 

!ty Strych. sulph 0.001 ~fy Strych. sulph 0.02 

Ferr. reduct o . 05 Ferr. reduct 1 . 

Quin. sulph o . 10 Quin. sulph 2 . 

M. et F. pil. M. et F. pil. 20 

S. A pill t.i.d., p.c. S. One three times a day, after 

meals. 



Capsules are often ordered instead of pills, and are frequently 
preferable, because they prevent the taste of disagreeable drugs, 
and because the drugs may be ordered in dry powder, and hence 
are more quickly absorbed after the capsule dissolves. To 
hasten solution or action, the cap may be taken on* the capsule 
just before swallowing. Ordinarily a capsule should not contain 
more than 0.30 gram. Most pills, capsules and tablets should 
not be taken on an empty stomach, unless plenty of water is 
taken with them. Most tablets should be crushed with the 
teeth before swallowing. 

Some drugs are well prepared and sold in elastic capsules, i.e., 
soft gelatin capsules. It has been shown that sometimes these 
soft capsules do not well dissolve, not as well as hard capsules. 
Hard gelatin capsules will dissolve in the stomach in five 
minutes, if there is no alcohol in the stomach. Soft gelatin 
capsules will generally not dissolve in pepsin solution at body 
temperatures until four hours or more, and may not dissolve 
at all. It is also uncertain how soon they will dissolve in the 
duodenal fluid, but if there is no desire for immediate action, 
flexible capsules will generally dissolve sooner or later in the 
alimentary canal and allow the activity of the drugs they 
contain. 

If one or more drugs are to be given in a larger dose than 
0.30 gram as a total weight, and a liquid preparation is unsatis- 
factory or inadvisable, the drugs should be given in powder, as 
follows: 



THE ART OF WRITING PRESCRIPTIONS 



35 



Stub 



Prescription for 20 Doses 



~Rf, Bism. subcarb. 
Sod. bicarb. . . 
M. et F. Chart. 
S. t.i.d., a.c. 



Gm. 

mil 
1. , 


M. 

S. 


Gm 

mil 
Bism. subcarb 20 


0.50 


Sod. bicarb 10 . 

et F. Chart. 20. 

A powder three times a day, be- 
fore meals. 



If a rectal suppository is ordered, it should be remembered 
that generally the size for an adult represents a weight of 2 or 
3 grams. 



% 



M. 

S. 



Stub 

Gm. 
mil 

Codein. sulph o . 04 

Atrop. sulph o . 0006 

01. theobrom 2 . 

et F. suppos. 
Use as directed. 



Prescription for 10 doses 

Gm. 
mil 

B) Codein. sulph o . 40 

Atrop. sulph o . 006 

01. theobrom 20 . 

M. et F. suppos. 10. 
S. Use one as directed. 



The drop is a measure belonging to no one system, and 
though it is inaccurate as an exact dose, it is a very useful dos- 
age for many preparations. No official dropper for a patient 
or a nurse to use is more accurate than a simple drop from the 
bottle. Of course the size of the drop depends on the size of 
the bottle's mouth and the character of the liquid, but a ten- 
drop dose to-day dropped from the same bottle of medicine 
to-morrow will pretty closely represent the same amount. As 
so many times stated, an absolutely accurate, unvarying dose 
of any preparation of any drug, prepared in any drug store, in 
any town, in any climate, for a patient with any disease, is 
impossible. The dose of any drug is the amount that will 
produce the effect desired; hence the dose should be increased 
if there is no action from it, and diminished if there is too much 
action. 



Stub 



Prescription 



Gm. 

mil 



Gm. 

mil 



Acid, hydrochl. dil 25 . 

10 drops, in water, three times a 
day, after meals. 



B; Acid, hydrochl. dil 

S. 10 drops in water, t.i.d., 
p.c. 

A number of ointments are official. They may be combined 
or other ingredients may be added to them. 



36 THE PRINCIPLES OF THERAPEUTICS 

Stub Prescription 

Gm. Gm. 

mil mil 

1^ Ung. zinc ox I* Ung. zinc ox 15. 

Ung. aq. ros aa Ung. aq. ros 15 . 

M. M. 

S. Use externally. S. Use externally. 

INCOMPATIBILITY 

The art of writing good prescriptions presupposes a knowl- 
edge of the antagonistic action of drugs, and a working, practical 
knowledge of ordinary chemical reactions. The administration 
of two drugs whose physiologic action is antagonistic, such as 
the coincident administration of strychnine and a bromide, or of 
digitalis and aconite, represents therapeutic incompatibility. 
However, a physician skilled in the use of drugs may modify an 
unpleasant action of a drug by giving coincidently another 
drug that counteracts such action, as, for instance, a bromide 
will control the unpleasant head symptoms caused by quinine. 
Bromide is a sedative to the central nervous system, and quinine 
is a stimulant to the central nervous system. Or, atropine 
may be given with morphine to antagonize the sedative action 
of the latter on the brain and respiratory center. Though cer- 
tain kinds of therapeutic incompatibilities are advisable, others 
are inexcusable — for instance, it is inexcusable to give a quinine 
and strychnine tonic after the evening meal, or to allow tea or 
coffee at the evening meal, and then to give a hypnotic at 
bedtime because the patient cannot sleep. 

Chemical incompatibility is closely related to Pharmacol 
incompatibility, and the latter can be avoided only by writing 
simple prescriptions and studying new combinations with the 
help and advice of a pharmacist. Many of the United States 
Pharmacopceial and National Formulary preparations are so 
carefully chemically balanced as to be thrown out of balance 
by the addition of most anything, and often even by more or less 
dilution; the change occurring may be precipitation, efferves- 
cence, or the formation of new chemical compounds. 

Gross chemical mistakes should not occur in prescription 
writing. To avoid such errors, the following brief list of 



THE ART OF WRITING PRESCRIPTIONS 37 

"do" and "don'ts" should be memorized. The chemical 
reason for such advice is not given, as reference to books on 
chemistry will elaborately outline the reactions. 

Prescribe alone: 

Acids, unless very dilute. 

Alkalies and alkaline carbonates in solution. 

Alkaloidal salts. 

Arsenic in solution. 

Ferric and ferrous salts. 

Iodides. 

Mercuric chloride. 

Tannic acid, tannates, and preparations containing 

tannates. 

Do not prescribe mercurous chloride (calomel) in a mixture 
that contains chlorides. 

Do not add water to preparations of resins, oleoresins, or 
to extracts or tinctures containing resins. 

Do not add water to official spirits. 

Do not add water to the tincture of strophanthus. 

DOSAGE 

. The average dose of a drug or preparation for an adult is 
given in the United States Pharmacopoeia. This dose must be 
reduced for children, but must be increased in many instances to 
obtain desired results. Also, medical opinion is often at vari- 
ance as to an average dose of a given drug, due, perhaps, to 
varying inertness or activity of a drug or preparation (and but 
few are really standardized), or due to some unusual personal 
experience. There is no one absolute dose of any drug; the 
dose is enough to do the work required; and, on the other hand, 
the symptoms of over-action or of cumulative effect should be 
quickly recognized. The average dose is modified by: (i) the 
age; (2) the weight; (3) abnormal physiology; (4) the pathologic 
condition present; (5) the frequency with which the dose is to 
be repeated. 



-S THE PRINCIPLES OF THERAPEUTICS 

i. Age. — This is, of course, of importance in administering 
drugs to children, and the following is a simple rule for comput- 
ing the dose: 

At 20 years the adult dose. 

At 10 years, half the age, half the dose. 

At 5 years, one-quarter the age, one-quarter the dose. 

At 2}i years, one-eighth the age, one-eighth the dose. 

At 1 year, one-twelfth the dose. 

If the child's age is between the ages given in the table, a 
little more or a little less, as the case may be, than the dose 
called for at the age in the table nearest the child's age will 
be the average dose. The table is simple and easy to remember, 
and represents the proper dosage for children, except when 
strong narcotic drugs are prescribed. The child's brain and 
central nervous system are relatively larger to its weight than in 
the adult, hence drugs that act strongly on the brain should be 
given in smaller doses than the above table would indicate. 

In old age the adult dose of strong drugs should often be 
reduced, as in the senile the physiologic processes are impaired, 
even if actual degeneration is not present, and hence a drug 
may cause excessive action. 

2. Weight. — The weight of a patient is really the scientific 
factor in determining the proper dose, hence the dose for an 
underweight child of five years should be less than that called 
for by the table, while an over- weight child of three years should 
often receive a dose for the five year period. A six-foot man 
requires a larger dose than a five-foot woman, if physiologic 
action of the drug is desired. However, over-weight due to fat 
and not size does not call for an increase in the dose, as fat does 
not represent an increase in the quantity of the blood, and it is 
the bulk of the blood (normally about one-thirteenth of the 
body weight) that really determines the dose. 

For ready reference it may be noted that: 

A normal baby five months old weighs about 15 pounds; at the 
end of a year, about 20 pounds; at the end of two years about 
30 pounds; and from then on he should gain from four to six 
pounds a year, until at fifteen the child should weigh not far 



THE ART OF WRITING PRESCRIPTIONS 



39 



from ioo pounds. Up to this period the boy and the girl 
weigh about the same. 

Careful investigation of many thousands of accepted insur- 
ance risks — in other words, of well individuals — has developed 
the following average weights for age and height : 



Men 



Age, years 


5 feet 


SH feet 


6 feet 


6M feet 


20 


117 


140 


160 


176 


30 


125 


145 


172 


190 


40 


130 


150 


180 


200 


5o 


135 


152 


183 


205 



A man's clothing weighs about seven pounds, his shoes with 
heels increase his height about one inch. 

Women on the average weigh about five to ten pounds less 
than men. An individual may weigh from twenty-five pounds 
below the average to twenty-five pounds above the average, 
and still be within the range of normal. Far below the average 
weight is more significant of latent disease under the age of 
thirty than above that age. Far above the average weight is 
more objectionable over the age of thirty than under that age. 

A family tendency to under- or over-weight is of importance 
in determining whether, or not, the individual is really abnormal 
and hence more likely to acquire disease or to become disabled. 

3. Abnormal physiology. — Any abnormal physiologic process 
may modify the dose of a drug, such as any stomach or intestinal 
disturbance that delays absorption; a liver disturbance that 
impairs its antidotal action; or any impairment of the excretory 
organs, especially of the kidneys. 

4. The pathologic condition present. — If any of the disturb- 
ances of physiology just suggested are caused by real pathologic 
conditions, the dose of a drug may need to be much less than the 
average, else poisoning may be caused. This is especially true 
in liver and kidney disease. On the other hand a pathologic 
condition may be present that requires a much larger dose than 



40 THE PRINCIPLES OF THERAPEUTICS 

the average to overcome that condition and cause the effect 
desired, such as an hypnotic action in cerebral excitement; for a 
narcotic effect in colic; or for the effect of digitalis on the heart 
in broken compensation or in auricular fibrillation. 

5. The frequency of the dose. — If a drug is slowly excreted, 
one dose of it a day may be of good size, while three or more 
doses a day must be smaller. A drug that is rapidly excreted 
may be given in full doses repeated as rapidly as it is known to be 
excreted. 

Alcohol, ammonia, and camphor act rapidly and are more or 
less rapidly excreted or rapidly destroyed in the body. Caffeine 
chloral, iodides, morphine, salicylates, strophanthus, and strych- 
nine act rapidly, but are more or less slowly excreted or slowly 
destroyed in the body. 

Arsenic, atropine, bromides, digitalis, mercury, quinine, and 
most synthetic antipyretic and hypnotic drugs act slowly, and 
are excreted slowly. 

On account of the slow excretion, and because only fractional 
parts of one or more doses are excreted in twenty-four hours, 
certain drugs when daily repeated, tend to accumulate in the 
system. Such drugs are arsenic, atropine, bromides, digitalis 
and mercury. 

CONDITIONS MODIFYING THE ACTION OF A DRUG 

1. Condition of the stomach, if a drug is given by the mouth. 

2. Intolerance : idiosyncrasy. 

3. Tolerance. 

1. The condition of the stomach really means the varying rate 
of absorption. — Theoretically, a drug received into an empty 
stomach should be more quickly absorbed than when the stomach 
contains food. This is generally true, as the drug is more 
rapidly passed into the intestine, where most absorption occurs. 
The stomach probably absorbs but few drugs, unless they long 
remain in the stomach, except alcohol and alcoholic prepara- 
tions, probably morphine, and most alkaloidal salts. 

When for any reason there is inertia of the stomach, from 
shock or dilatation, or from sluggish circulation, a drug may 
remain for a long time in the stomach unabsorbed. Conse- 



THE ART OF WRITING PRESCRIPTIONS 41 

quently , in all such conditions a drug whose action is immediately 
desired must be given by some other avenue than the stomach. 

Most drugs are satisfactorily given after meals, unless they 
are known to seriously delay digestion, and many drugs retard 
digestion more or less. A drug known to greatly delay digestion 
should be given two hours after meals, or long before a meal. An 
irritant drug or preparation should ordinarily not be given on an 
empty stomach, unless the drug is well diluted. A drug that 
irritates the stomach may cause pain and vomiting, or may 
cause inflammation and even ulceration. Some drugs may 
irritate, and at the same time not cause recognizable pain. 
This is true of some tablets, such as bromides, chloral, potas- 
sium chlorate, etc. Hence only tablets known to be absolutely 
non-irritant should be swallowed whole. 

Some drugs are destroyed in the stomach, or are at least 
changed so that their activities are impaired, or they may cause 
nausea. Such drugs may be given in pills coated with some 
protective covering that is not acted upon by the gastric juice. 
The hydrochloric acid of the stomach may chemically change 
many drugs and preparations, but generally not to their impair- 
ment, and such changes often hasten absorption. It is obvious, 
if the mucous membrane of the stomach is to be treated, that 
medicaments must be given on an empty stomach. It is also 
obvious that a bitter tonic, or a gastric stimulant or appetizer 
should just precede the meal. The more soluble the drug is 
in acid media and the better the solution of the drug, the quicker 
it must be absorbed. However, speed of absorption is not 
always a necessary requirement, hence very many drugs are 
given in less soluble, but more pleasant, forms than solutions. 

2. Intolerance. — Many conditions may cause an intolerance 
to a drug. In other words, an average dose of a drug may cause 
unexpected, unpleasant, or severe symptoms. Certain diseases, 
especially of the central nervous system, of the liver, of the 
kidneys, and some diseases of the endocrine glands may cause 
an intolerance to certain drugs. On the other hand, some in- 
dividuals who are well are intolerant to certain drugs and remain 
so all their lives. This is termed an "idiosyncrasy'' against 
such drugs. The drugs against which there is most frequently 



42 THE PRINCIPLES OF THERAPEUTICS 

an idiosyncrasy, or intolerance, are belladonna and iodides. 
Drugs against which there is less frequently intolerance, but 
common enough to be noted, are opium and its alkaloids; 
mercury, especially calomel; bromides (even a single dose of ten 
causing an eruption); quinine; and salicylates. An individual 
who cannot take morphine or any other narcotic for severe 
pain is very unfortunate, but such a patient is occasionally 
found. Some patients cannot take quinine without being 
severely poisoned. Others, after the first poisoning symptoms 
from quinine or some other drug, become more or less tolerant 
and can take ordinary doses of it for that particular period, to 
be again poisoned at some other time. Some of these excessive 
reactions from drugs are anaphylactic in character, being ac- 
companied by fever and other symptoms of anaphylaxis. An 
individual found to have an idiosyncrasy against any particular 
drug should be informed of the fact, that he may warn his 
future physicians and not be again unnecessarily poisoned. 

3. Tolerance. — Certain diseases cause a tolerance for certain 
drugs, such as most patients with malarial fever will tolerate 
large doses of quinine; those with syphilis, large doses of mer- 
cury and iodides; those with epilepsy large doses of bromides. 
Also, certain diseases of the endocrine glands cause a tolerance 
to drugs. A tolerance to a drug is acquired by long taking of 
that drug, and such tolerance is found in drug addicts, those 
who use morphine or cocaine, in excessive users of tobacco, and 
even in those who constantly use cathartics. Such individuals 
become tolerant to the class of drugs to which they are accus- 
tomed, and may be intolerant to other drugs. 

CUMULATIVE EFFECTS OF DRUGS 

The cumulative action of a drug is evidenced by sudden un- 
expected mild symptoms of poisoning. This occurs when 
certain drugs are given in too rapidly repeated doses, so that 
excretion of one dose cannot occur before the next one or more 
doses are taken. The result is an accumulation of the drug in 
the system until there is developed a sudden intolerance, and 
more or less severe poisoning occurs. At other times, owing to 



THE ART OF WRITING PRESCRIPTIONS 43 

some sudden disturbance of the organs of excretion a drug 
ordinarily well excreted is retained, and poisoning occurs. 

Another form of cumulative action takes place when certain 
drugs have been long taken and symptoms of chronic poisoning 
occur. At times certain drugs are pushed to the degree of 
primary poisoning, or until full physiologic limit is reached, to 
obtain desired therapeutic results. This is done deliberately, 
and the first symptoms of poisoning are watched for and quickly 
noted, and the administration of the drug is stopped. 

The recognition of the over-action of a drug, the recognition 
of chronic drug poisoning, perhaps not even suspected, and the 
treatment of these conditions can be acquired only by book and 
laboratory study of the pharmacology of drugs. 

It should be borne in mind when giving drugs to nursing 
mothers that many drugs are excreted in the milk, and may 
affect the child. These drugs are opium and its alkaloids, most 
hypnotics, bromides, arsenic, mercury, iodides, quinine, thyroid 
extract and probably other organ extracts, and most cathartics. 
At times, however, it is desirable to treat a babe through its 
mother's milk. 

Many drugs cause eruptions on the skin, most frequently an 
urticaria or an efflorescence, similar to the scarlet fever rash. 
Part of this action is due to duodenal irritation quite similar 
to a food poisoning, as from fish or strawberries, which foods so 
frequently cause eruptions in some individuals. The drugs 
most likely to cause eruptions are arsenic, atropine, chloral, 
coal-tar drugs as antipyrine and phenols, copaiba, opium, 
quinine, mercury, salicylic acid and some salicylates, santal oil, 
synthetic hypnotics as sulphonal, thyroid, and volatile oils. 
At times these drugs, in a few individuals, may cause real 
anaphylactic conditions, with serious eruption and swelling of 
the skin, or a dermatitis, giant urticaria, or angioneurotic 
edema. Antitoxins and serums may cause such symptoms, 
and may even cause death from protein poisoning. 

Some drugs cause irritation of the skin during their excretion 
through the glands of the skin. Bromides, especially if long 
taken, often cause pustular acne, and at times more serious skin 
eruptions. Iodides cause non-pustular acne. 



44 THE PRINCIPLES OF THERAPEUTICS 

DRUGS WHICH MAY CHANGE THE COLOR OF THE URINE 

Drugs that increase the amount of urine cause it to be 
lighter, while drugs that irritate the kidneys cause the urine to 
be darker. Methylene blue causes the urine to be green, if it is 
acid. Phenol, or any phenol containing drug, may cause 
the urine to be dark brown. Santonin causes it to be yellow, 
if acid; purple, if alkaline. Senna may cause it to be red, if 
alkaline; yellow, if acid. Sulphonal and other synthetic 
drugs may cause the urine to be dark. 

DRUGS WHICH COLOR THE FECES 

Bismuth salts color the feces black or dark gray; iron colors 
them black; colchicum and mercury in sufficient doses to 
cause purging color them green; and vegetable purgatives 
cause them to be darker than normal. 

ADMINISTRATION OF DRUGS 

Some drugs act locally only, when applied to the skin and 
mucous membranes, or to the gastrointestinal canal. Even 
many cathartics act as such on account of the irritation of the 
intestinal walls that they cause. Drugs that act on some part 
of the general system must first be absorbed into the blood, and 
they reach the blood: (i) by absorption from the stomach and 
intestines after their administration by the mouth in capsules, 
pills, tablets, liquids, or powders; (2) by absorption from the rec- 
tum after their administration as suppositories or enemata; (3) 
by absorption from any other mucous membrane with which 
they are in contact; (4) by absorption after their inhalation; 
(5) by absorption from the skin after their inunction or after 
their prolonged contact with the skin; (6) by absorption from 
the subcutaneous tissues after their hypodermic injection; 

(7) by absorption from muscular tissue after their deep injection 

(8) by their direct introduction into the blood stream by 
intravenous injection. 



the art of writing prescriptions 45 

Rapidity of Absorption 

This occurs in the following order, the most rapid route 
heading the list: 

1. When the drug is given intravenously. 

2. When the drug is given hypodermatically. 

3. When the drug is brought into contact with mucous 
membranes, especially the nose. 

4. When the drug is given by the stomach. 

5. When the drug is given by the rectum. 

6. When the drug is rubbed into the skin. 

The size of the dose depends on the rapidity of the absorp- 
tion; in other words, the dose should be the smallest when it is 
given intravenously, and the largest when it is rubbed into the 
skin. The length of time before a given dose will be excreted 
is in the inverse order of the above list. 

For certain diseases and conditions drugs and serums are 
administered intraspinally. 



PART II 
DRUGS 

In this age of antitoxins, serums, vaccines and organotherapy, 
and the consequent tendency to drug nihilism, it is well to 
study from a therapeutic standpoint the really useful drugs. 
These drugs are presented in three ways: 

First, as the valuable drugs and preparations of the United 
States Pharmacopoeia. 

Second, as a classification of useful drugs, based on their 
therapeutic uses. 

Third, as a brief description of the action, uses, and methods 
of administration of the most therapeutically active of these 
drugs. 

Alphabetical List 

of 

Valuable Drugs and Preparations of the U* S* P* 

ACACIA — Gum Arabic 

Preparations. — Mucilago Acacia; Syrupus Acacia. 
Comment. — All preparations of acacia should be freshly 
made. 

ACETANILIDUM— Antifcbrin 

Acetanilid occurs as a white crystalline powder, which is 
slightly soluble in water. 

Comment. — The average dose is o.io Gm. (i^ grains), 
best administered in powder or in tablet (to be crushed before 
swallowing) and taken with plenty of water. 

ACETPHENETIDINUM— Phenacetin 

Acetphenetidin occurs as a white crystalline powder, is 
insoluble in water, and the average dose is 0.30 Gm. (5 grains). 

Comment. — It is best administered in powder or tablet (to be 
crushed before swallowing) and taken with plenty of water, 

46 



DRUGS AND PREPARATIONS OF TJ. S. P. 47 

ACIDUM ACETICUM GLACIALE 

Comment. — Glacial acetic acid is a colorless liquid used 
only as an escharotic. 

ACIDUM BORICUM— Boracic Acid 

Boric acid occurs as transparent scales or white powder, and 
is soluble in 4. or 5 per cent, of water. 

Preparations. — Glyceritum Boroglycerini; Unguentum Acidi 
Borici. 

Comment. — Boric acid should not be used internally. It is 
very valuable locally in inflammations of mucous membranes, 
on wounds and local infections, best in saturated solutions, 
which is about 4 per cent, in cold water. It is used as a dusting 
powder and for dressings. The ointment contains 10 per cent, 
of boric acid. 

ACIDUM CITRICUM 

Citric acid is obtained from the juice of limes or lemons, 
and occurs as colorless prisms or as a white powder, is very 
soluble in water, and the average dose is 0.50 Gm. (7^ grains). 

Preparation. — Syrupus Acidi Citrici. 

Comment. — The syrup of citric acid contains 1 per cent, of 
citric acid and 1 per cent, of tincture of lemon peel, and is a 
very useful addition to prescriptions that need a little sweeten- 
ing, but not the sweet furnished by a thick nauseating syrup. 

ACIDUM HYDROCHLORICUM DILUTUM— Dilated Muriatic 

Acid 

Diluted hydrochloric acid is a colorless liquid representing 
10 per cent, of hydrochloric acid. 

Comment. — It aids gastric digestion, stimulates intestinal 
secretions, and increases the acidity of the urine. It is useful 
in all cases of insufficient hydrochloric acid in the stomach, is 
often useful in anorexia, and is of benefit when there is a 
flabby, coated tongue. The average dose is 0.5 mil (7 minims), 
which should be taken well diluted, after meals. More water 
should be taken afterwards to thoroughly cleanse the mouth. 



48 THE PRINCIPLES OF THERAPEUTICS 

ACIDUM NITRICUM 

Nitric acid is a fuming liquid, which is used only as an 
escharotic. 

ACIDUM PHENYLCINCHONINICUM— Atophan— Cinchophen 

Phenylcinchoninic acid occurs as small needles or as a 
yellowish- white powder, has a bitter taste, and is soluble in 
water. 

Comment. — It is best given in powder or capsule, and the 
average dose is 0.30 Gm. (5 grains). Large doses are likely 
to cause a large output of uric acid in the urine. 

ACIDUM PHOSPHORICUM DILUTUM 

Diluted phosphoric acid is a clear, colorless liquid represent- 
ing 10 per cent, of phosphoric acid. 

Comment. — This preparation has no other action than that 
of a pleasant acid. The dose is 1 mil (15 minims), given well 
diluted. 

ACIDUM SALICYLICUM 

Salicylic acid occurs in fine needles or as a crystalline powder, 
has a disagreeable, sweet taste, and is slightly soluble in water. 
The average dose is 0.75 Gm. (12 grains). 

Comment. — Salicylic acid is used externally as an antiseptic 
and as a mild escharotic. To remove warts, corns and callous 
skin it may be used in 10 to 20 per cent, ointment, or in a 
solution of collodion, 1 Gm. to 30 mils. When administered 
internally it should be ordered in powder to be taken with a 
large amount of water, but, as it is likely to cause nausea and 
vomiting, it is much better to use the salt, sodium salicylate, 
rather than this preparation. 

ACIDUM TANNICUM— Tannin 

Tannic acid occurs as a yellowish- white powder, is dis- 
agreeably astringent in taste, and is soluble in water and glycerin. 
The average dose is 0.50 Gm. (7^ grains). 

Preparations. — Glyceritum Acidi Tannici; Trochisci Acidi 
Tannici; Unguentum Acidi Tannici. 



DRUGS AND PREPARATIONS OF U. S. P. 49 

Comment. — Tannic acid is disagreeable and nauseating, and 
for action on the bowels is best administered in capsule. It is 
not much used internally, as pleasanter preparations of tannic 
acid can be obtained, i or 2 per cent, solutions of tannic acid, 
or a 5 per cent, solution of glycerite of tannin may be used as 
mouth washes or gargles, and tannic acid troches may be dis- 
solved in the mouth for local astringent effect. Each troche 
contains 1 grain of tannin. The ointment contains 20 per 
cent, of tannin. 

ACIDUM TARTARICUM 

Tartaric acid occurs as a white powder, has an acid taste, 
and is very soluble in water. The average dose is 0.50 Gm. 
ilH grains). 

Comment. — Tartaric acid is rarely given internally, except 
in effervescing combinations. It is contained in the white 
paper of the official Compound Effervescing Powder (Seidlitz 
Powder). 

ACIDUM TRICHLORACETICUM 

Trichloracetic acid occurs in crystals, which are very soluble 
in water. 

Comment. — This acid is used only externally, in saturated 
solution, as an escharotic, and is said to be a specific for Vincent's 
angina. After a thorough application it should be neutralized 
with a saturated solution of sodium bicarbonate. 

ACONITUM— Monkshood 

Aconite is used only in its preparations, the best of which is 
Tinctura Aconiti. 

Comment. — The tincture of aconite contains 10 per cent of 
aconite, and the average dose of an active preparation is one 
drop every half hour until there is evidence of its physiologic 
action. The official alkaloid Aconitina is too strong a prepar- 
ation to be used in medicine; a very small dose has no value 
and a larger dose may cause toxic symptoms. 

ADEPS BENZOINATUS 
Comment. — Benzoinated lard contains 1 per cent, of benzoin. 



50 



THE PRINCIPLES OF THERAPEUTICS 



ADEPS LANJE— Wool Fat 

Comment.— Anhydrous lanolin is used externally only, and 

will take up twice its weight in water, with which it readily 

mixes. 

ADEPS LANiE HYDROSUS— Lanolin 

Comment. — Hydrous wool fat contains 25 to 30 per cent, of 
water. It is very soothing to the skin. 

ETHER— Ether 
Comment. — There is no use for ether or its official preparation, 
Spiritus Mtheris, internally. 

JETHYLIS CHLORIDUM 

Ethyl chloride occurs as a white volatile liquid in hermeti- 
cally sealed containers. It is sprayed upon a part to cause 
freezing and local anesthesia. 

ALOE 

Aloes occurs as a yellowish or brownish powder. 

Preparations. — Pilulce Aloes; Piluloz Rhei Composites, Aloi- 
num, which occurs as a fine, crystalline yellow powder, of an 
intensely bitter taste, and represents the activities of aloes. 

Comment. — Aloes is a stimulant to the muscular coat of the 
intestine, especially the large intestine, and may congest and 
irritate the rectum and pelvic organs ; hence it is generally best 
not to administer aloes, except in small doses, during pregnancy, 
when there are hemorrhoids, or when there is rectal or pelvic in- 
flammation. Large doses cause colicky pains, and hence it is not 
a good purgative, but aloes, best in the form of aloin or in one 
of the pills, is a good laxative, generally best given in combi- 
nation. It should be given in pill, in capsule, or in tablet, either 
at bedtime or directly after the evening meal. Aloes should 
not be given to nursing mothers, as it is excreted in the milk. 
Each official pill of aloes contains 2 grains. The dose is one or 
two pills. Each of the compound rhubarb pills contains i^i 
grains of aloes and 2 grains of rhubarb. The dose is one or two 
pills. The average dose of aloin is 0.015 Gm. (J£ grain). This 



DRUGS AND PREPARATIONS OF U. S. P. 51 

dose is rather small, and the following combination for a pill or 
tablet is suggested. 

Strychnine sulphate o . 0015 Gm. 

Aloin 0.02 Gm. 

Powdered ipecac o . 03 Gm. 

Extract of belladonna 0.01 Gm. 



In place of the belladonna, atropine sulphate could be used, 
0.0003 Gm. (Moo grain) to each pill or tablet. Many other 
combinations of so-called "A.B.S." pills or tablets are offered. 

ALUMEN— Al«m 

Alum occurs as colorless crystals or white powder. It has a 
sweetish, astringent taste. 

Comment. — Alum is an astringent and an emetic. There is 
no use for this preparation internally. Alum pencils or cakes 
are used as an astringent in cankers, on the face after shaving, 
or to harden any part of the skin; they are, also, used on granu- 
lar eye-lids and on herpes zoster (cold sores). Alum curds 
have been used for inflammations of the eye (2 Gm. of alum to 
the white of one egg). Alum should not be used as a mouth 
wash or as a gargle, as it is not good for the teeth. It may be 
used in 1 or 2 per cent, solution as a vaginal douche for leucor- 
rhea, and in stronger solutions for pruritus ani and vulvae. 
It should probably be used more frequently as a sedative as- 
tringent in skin diseases. The official Alumini Hydroxidum is 
an efficient dusting and drying powder. The official Alumen 
Exsiccatum (Dried Alum — Burnt Alum) is a mild escharotic. 

AMMONII CARBONAS 

Ammonium carbonate occurs in hard white masses, having a 
strong odor of ammonia. It is soluble in water. 

Comment. — This preparation is irritating and nauseating, of 
doubtful value as a stimulant, and as an expectorant ammonium 
chloride is better. The official preparation (Spiritus Ammonice 
Aromaticus) so long used as a cardiac stimulant, is of doubtful 
value, except for the action of the alcohol that it contains. 



52 THE PRINCIPLES OF THERAPEUTICS 

AMMONII CHLORIDUM 

Ammonium chloride occurs in white crystals or granular 
powder, has a disagreeable saline taste, and is very soluble in 
water. The average dose is 0.30 Gm. (5 grains). 

Preparation. — Trochisci Ammonii Chloridi. Each troche 
contains i}i grains of ammonium chloride. 

Comment. — This salt is generally given combined, and should 
be taken well diluted. As an expectorant it may be given in 
the above dose every two or three hours. As it is disagreeable, 
it is best given in a sour preparation, as : 

Ammonium chloride 5 Gm. 

Syrup of citric acid 25 mils 

Water up to 100 mils 

Mix and sign: A teaspoonful, in plenty of water, every two or three hours. 

If it is desired, codeine sulphate may be added to this mixture 

for sedative purposes. 

AMYLIS NITRIS 

Amyl nitrite is a clear or yellowish liquid, has a pungent, 
fruity odor, and is very volatile. 

Comment. — This preparation is best obtained in glass am- 
pules, to be crushed and the contents inhaled. 

ANTIMONII ET POTASSII TARTR AS— Tartar Emetic 

Antimony and potassium tartrate occurs as colorless crystals 
or a white powder and has a sweet but disagreeable taste. 

Comment. — It is an emetic, is depressant to the circulation 
and nervous system, and increases the secretions. Small doses 
long continued may cause serious chronic poisoning, simulating 
that of arsenic and phosphorus. Acute poisoning causes 
collapse. The treatment of such poisoning is to wash out the 
stomach, give tannic acid, and cardiac supporting treatment. 
There is no use for this drug. The official preparation which 
contains it, Mistura Glycyrrhizm Composita (Brown Mixture), 
is not needed. 

ANTIPYRINA— Phenazone 

Antipyrine occurs as a white crystalline powder, has a slightly 
bitter, disagreeable taste, and is very soluble in water. 



DRUGS AND PREPARATIONS OF U. S. P. 53 

Comment. — The average dose is 0.50 Gm. (7^ grains), best 
administered in a capsule. The capsule may be uncapped 
before taking with plenty of water. 

APOMORPHIN^E HYDROCHLORIDUM 

Apomorphine hydrochloride is the salt of an alkaloid prepared 
from morphine, and occurs in minute whitish prisms. It is not 
very soluble in water. 

Comment. — This preparation should be used only as an 
emetic, and best hypodermatically, in the dose of 0.006 Gm. 
(Ho grain). 

AQUA H AM AMELIDIS— Distilled Extract of Witchhazel 

Witchhazel water is a colorless liquid, is mildly astringent, 
and is very popular for use on the skin and mucous membranes. 

ARGENTI NITRAS 

Silver nitrate occurs as colorless crystals, which are very 
soluble in water. Both crystals and solutions soon turn black 
on exposure to light. 

Comment. — There is no excuse for using silver nitrate inter- 
nally. It may be used externally in solutions of various 
strength for its stimulating and escharotic action. The 
official preparation, Argenti Nitras Fusus (Lunar Caustic), 
occurs as white soluble pencils, which are used for escharotic 

purposes. 

ARSENI IODIDUM 

Arsenous iodide occurs as orange-red crystals or powder, 
which are soluble in water. The average dose is 0.005 Gm. 
(H2 grain). 

Comment. — The action of this salt is that of arsenic. Its 
only preparation, Liquor Arseni et Hydrargyri Iodidi (Donovan's 
Solution), is superfluous and unnecessary. 

ARSENI TRIOXIDUM— Arsenous Acid— White Arsenic 

Arsenic trioxide occurs as an opaque white powder or in 
masses. It is soluble in water, and the average dose is 0.002 
Gm. (3^0 grain). 



54 THE PRINCIPLES OF THERAPEUTICS 

Preparation. — Liquor Potassii Arsenitis (Fowler's Solution). 
This is a i per cent, solution of trioxide of arsenic, the average 
dose of which is 0.2 mil (3 minims). 

ASAFETIDA 

Asafetida occurs as a gum-resin. 

Preparation. — Pilules Asafoetidce. 

Comment. — Asafetida is a carminative like onions and garlic, 
and is of no use in medicine, except in flatulence and intestinal 
inertia. It has been thought to be of special value for tympa- 
nites after laparotomy, but hypodermatic injections of ergot 
and pituitary extracts are much more efficient. Intestinal 
paresis will not as frequently occur when strong purgation is 
not caused before operation. The best method of administering 
asafetida is by means of the official pill. Each pill contains 3 
grains of asafetida and the dose is one or two pills. 

ASPIDIUM— Male Fern 

Aspidium occurs as the rhizome and stipes of the plant. 

Preparation. — Oleoresina Aspidii. 

Comment. — This drug is used only for the eradication of 
tapeworms, and generally in the form of the oleoresin. An over- 
dose may cause vomiting, diarrhea, tremors, and convulsions. 

In the treatment of tapeworm the method is to starve, purge, 
give the dose of the oleoresin of aspidium, then to purge again, 
as the drug must not be allowed to remain long in the bowels 
lest a poisonous amount be absorbed. Oil should not be 
administered before, with, or directly after the oleoresin. 
The oleoresin is well given in capsules, each capsule containing 
0.50 Gm. (7^ grains). Two of these capsules, representing 
1 Gm., should be taken at the time directed, with plenty of 
water, and just before swallowing the capsules should be 
uncapped. The same dose should be repeated in two hours, 
namely, two capsules (1 Gm.). In two more hours a purgative 
should be administered. 

ASPIDOSPERMA— Quebracho 

Comment. — This drug has been recommended for use in 
asthma. It is of doubtful efficiency, and is used only as the 



DRUGS AND PREPARATIONS OF U. S. P. 55 

official fluid-extract, Fluidextr actum Aspidospermatis, in doses 
of about a teaspoonful. It has also been used in the form of 
the alkaloid, aspidospermine. 

ATROPINA 

Atropine is an alkaloid of belladonna. 

Comment.— Atropine is used mostly in the form of the 
sulphate, Atropines Sulphas, which occurs as a white crystal- 
line powder, very soluble in water. The average dose is 
0.0005 Gm - (M20 grain). 

BALSAMUM PERUVIANUM 

Balsam of Peru is a viscid liquid of a dark brown color, and 
has a pleasant odor. 

Comment. — It is used externally as a mild antiseptic and 
stimulant to indolent ulcerated surfaces. It is an efficient 
parasiticide in scabies. 

BALSAMUM TOLUTANUM 

Preparation. — Syrupus Tolutanus. 

Comment. — Balsam of Tolu is used principally in the form of 
the syrup as a pleasant menstruum in cough mixtures. 

BELLADONNA FOLIA— BELLADONNA RADIX— Deadly 
Nightshade 

The leaves and root of Atropa Belladonna. 

Preparations. — Emplastrum Belladonna; Unguentum Bello- 
donnce. 

Comment. — There are other preparations of belladonna, 
but as atropine represents the whole activity of belladonna, 
there is no necessity for the use of any preparations except 
those above named. The ointment of belladonna contains 
10 per cent, of the drug and is slightly sedative to the part to 
which it is applied. The plaster of belladonna is sedative. 
Too large a plaster should not be used at once, as the atropine 
in the plaster can be absorbed and cause belladonna and atro- 
pine poisoning. The official liniment of belladonna is an inexcus- 
able preparation. It is too dangerous for use. 



56 THE PRINCIPLES OF THERAPEUTICS 

BENZOINUM— Gum Benjamin 

Benzoin occurs as a balsamic resin. 

Preparation. — Tinctura Benzoini. 

Comment. — Benzoin is never used as such. The compound 
tincture has often been used to add to mixtures for inhalation, 
but the plain tincture of benzoin is as valuable. 

BENZOSULPHINIDUM— Saccharin— Glwsidum 

Saccharin occurs as white crystals or powder, has an intensely 
sweet taste, and is not very soluble in water. 

Comment. — Saccharin has no medicinal properties. It is 
used in very small doses, as 0.006 Gm. (34 g ram ) to 0.015 Gm. 
(H grain) as a sweetener for foods and drinks for diabetics. 
There is really no necessity for such use, as a diabetic patient 
soon learns to go without the sweet taste to his foods. Long 
continued use of saccharin or larger doses may cause consider- 
able gastrointestinal indigestion. A more soluble preparation 
of saccharin is the official Sodii Benzosulphinidum. 

BETAEUCAINE HYDROCHLORIDUM— Eucaine Chloride 

Betaeucaine Hydrochloride occurs as a white crystalline 
powder, soluble in water (1 Gm. in 30 mils). 

Comment. — Betaeucaine is used as a local anesthetic in 0.1 
per cent solutions. Novocaine and procaine are the same as 
betaeucaine. 

BETANAPHTHOL— Naphthol 

Betanaphthol occurs as a colorless or yellowish crystalline 
powder, practically insoluble in water, soluble in alcohol. 

The average dose is 0.25 Gm. (4 grains). 

Comment. — Betanaphthol is a mild germicide both externally 
and internally, and is used as an intestinal antiseptic. On the 
skin it is irritant in strong preparations, and is used in oint- 
ments in 5 to 10 per cent, strength for some skin diseases. It 
is almost insoluble in the stomach. It breaks up in the intes- 
tines causing some antiseptic action, and may cause symptoms 
similar to mild phenol poisoning. It is not as much used as an 
intestinal antiseptic as is salol, as it is much more likely to cause 



DRUGS AND PREPARATIONS OF U. S. P. 57 

poisoning, and is no more efficient. It is used largely in un- 
cinariasis, though thymol and oil of chenopodium are better. 
It should be administered in capsules. 

BISMUTHI BETANAPHTHOLAS— Orphol 

Bismuth betanaphthol is a compound of bismuth and beta- 
naphthol. It is insoluble in water, and the dose is 0.50 Gm. 
(iH grains). 

Comment. — This preparation has been used for diarrhea, 
(best administered in capsules), but a prescription for bismuth 
subcarbonate and phenyl salicylate (salol) is better for this 
condition. 

BISMUTHI SUBCARBONAS 

Bismuth Subcarbonate occurs as a yellowish-white powder, 
which is insoluble in water. 

Comment. — This is a better preparation to use internally, 
ordinarily, than is bismuth subnitrate, although the latter is 
the most frequently prescribed. The average dose is 1 Gm. 
(15 grains). 

BISMUTHI SUBGALLAS— Dermatol 

Bismuth Subgallate occurs as a bright yellow powder, which 
is insoluble in water. The average dose is 0.50 Gm. (7^ 
grains) . 

Comment. — This preparation is more frequently used as a 
mild astringent drying powder for irritations of the skin. It 
has no advantage over other preparations of bismuth when 
used internally. 

BISMUTHI SUBNITRAS 

Bismuth subnitrate occurs as a white powder, which is 
insoluble in water. 

Preparation. — Magma Bismuthi (Milk of Bismuth), the 
dose of which is a teaspoonful. 

Comment. — The Milk of Bismuth preparation is a compound 
mixture that does not keep well, and it is much better to admin- 
ister bismuth subcarbonate or bismuth subnitrate as a powder 
dropped into some effervescing water, as vichy, for an adult, 



5 S THE PRINCIPLES OF THERAPEUTICS 

or in barley water or milk for a child. The average dose of 
bismuth subnitrate is i Gm. (15 grains). 

BUCHU 

Buchu occurs as the dried leaves of the plant. 

Preparation. — Fluidextr actum Buchu, the dose of which is 
2 mils (30 minims) taken well diluted, four times a day. 

Comment. — Buchu is a mild stimulating diuretic, and hence 
should not be used when there is inflammation of the kidneys. 
It has been given as a decoction made with 30 Gm. (1 ounce) 
of the leaves to 500 mils (1 pint) of water. The whole pint 
should be taken during the twenty-four hours. 

C AFFEINA— Caffei ne— T hei ne 

This substance is obtained from the leaves of tea (theine) 
and the seeds of coffee (caffeine), and occurs as white silky 
needles of very bitter taste, and not very soluble in water. 

Preparations. — Cafeina Citrata; Caffeina Citrata Efferves- 
cens. 

Comment. — Caffeine is principally used in the form of the 
citrated caffeine, and the average dose is 0.30 Gm. (5 grains) ; 
or in the form of the effervescing citrated caffeine, which 
contains 4 per cent, of citrated caffeine, the average dose of 
which is 4 Gms. (1 drachm). 

CAFFEINiE SODIO-BENZOAS 

This substance is a mixture of caffeine and sodium benzoate, 
and occurs as a white powder, has a slightly bitter taste, and is 
very soluble in water. 

Comment. — This preparation is used mostly hypodermatic- 
ally, and the hypodermic dose is 0.20 Gm. (3 grains). 

CALCII CARBONAS PRiECIPITATUS— Precipitated Chalk 

Precipitated calcium carbonate occurs as a fine white crystal- 
line powder, is tasteless, and is insoluble in water. 

Comment. — This preparation is mostly used as a dusting 
powder to dry moist surfaces. Sometimes it is used as an ant- 



DRUGS AND PREPARATIONS OF U. S. P. 59 

acid, and to allay stomach and intestinal irritation. The average 
dose for this purpose is i Gm. (15 grains). 

CALCII CHLORIDUM 

Calcium chloride occurs in white, hard fragments, is very 
delequescent, and very soluble in water. 

Comments — Calcium chloride is used to increase the calcium 
content of the blood when there is bleeding, but it is irritant 
and nauseating, and hence the preparations of calcium lactate 
and calcium glycerophosphate are better. If this drug is used, 
the dose should be 0.30 Gm. (5 grains). It is best prescribed 
with some syrup, as syrup of acacia, and water, and should be 
taken well diluted. 

CALCII GLYCEROPHOSPHAS 

Calcium Glycerophosphate occurs as a fine white powder, 
has a slightly sweetish taste, and is not very soluble in water. 

Comment. — This is a very useful preparation and a pleasant 
method of administering calcium, and represents the most 
important ingredient of the various glycerophosphate prepara- 
tions. It acts as a nervous sedative. The dose to satisfy the 
calcium need of the body is about 0.50 Gm. (7^ grains) given 
in powder, or in capsule, three times a day. 

CALCII LACTAS 

Calcium Lactate occurs as white masses or powder, is nearly 
tasteless, and not very soluble in water. 

Comment. — Calcium is a specific for tetany and for any 
irritation or insufficiency of the parathyroid glands. Most 
calcium preparations are nervous sedatives, and they may also 
be used when there are frequent hemorrhages. The average 
dose is 0.30 Gm. (5 grains), best given in powder. 

CALCII SULPHIDUM CRUDUM— Sulphurated Lime 

Crude Calcium Sulphide occurs as a grayish or yellowish 
powder, has a faint odor of hydrogen sulphide, a disagreeable 
taste, and is insoluble in water. 



60 THE PRINCIPLES OF THERAPEUTICS 

Comment. — Sulphurated lime has been used for boils and 
carbuncles, and for pustular inflammations of the skin. What- 
ever value it has is probably due to its sulphur content, and 
other preparations of sulphur will doubtless act as well. In all 
such pustular conditions it should be remembered that focal 
infection must be sought and eradicated. An average dose is 
0.05 Gm. Q4 g ram )> every three hours, best administered as a 
tablet, which should be crushed before swallowing and taken 
with plenty of water. 

CAL X — Calciu m Oxide — Li me — Quicklime 

Comment. — This drug is administered internally only in the 
form of its preparation, Liquor Calcis, the dose of which is a 
tablespoonful, administered from two to four times a day, 
either in milk or water. Lime water is a mild antacid which is 
often added to milk in the preparation of artificial food for 
children, as the alkali tends to prevent the formation of large 
curds in the stomach, hence thought to allow the milk to be 
more easily digested. A small amount of calcium is doubtless 
absorbed from this preparation. 

CALX CHLORINATA— "Chloride of Lime" 

Chlorinated lime occurs as a white or grayish granular 
powder giving off the odor of chlorin, of which it should contain 
not less than 30 per cent. It is partially soluble in water. 

Comment. — This is used as a disinfectant in the strength of 
60 Gm. to 1,000 mils (2 ounces to a quart) for disinfecting 
stools and urine. The official Liquor Sodcz Chlorinates (Labar- 
raque's Solution) is largely used as an antiseptic wash. 

CAMPHORA 

Camphor occurs as white masses, has a characteristic pungent 
odor, is slightly soluble in water, and very soluble in alcohol. 
The average dose by the mouth is 0.20 Gm. (3 grains). Hypo- 
dermatically the dose is 0.10 Gm. (i}4 grains). 

Preparations. — Aqua C amphora is a very weak preparation 
of camphor, the average dose of which is 2 teaspoonfuls. 



DRUGS AND PREPARATIONS OF U. S. P. 6l 

Spiritus Camphor <z contains 10 per cent, of camphor, and the 
dose is i mil (15 minims). 

CANNABIS — Cannabis Indica — Indian Hemp — Hashish 

Comment. — Cannabis Indica is a cerebral stimulant and 
sexual excitant. Later it causes soothing, pleasurable sen- 
sations and sleep. It is a habit-forming drug, and its medicinal 
value is doubtful. If used for medicinal purposes the best 
preparation is the official fluid extract, the average dose of 
which is 0.10 mil (ij^ minims). Preparations of cannabis 
vary greatly in strength. 

C ANTH ARIS— Ca n t harides— S pa nis h Flies 

The preparations of Ceratum Cantharidis, Collodium Canthari- 
datum, and Tinctura Cantharidis are made from the dried 
bodies of Spanish beetles. Cantharis is used externally to 
cause blisters in the form of the cerate, as plasters made from 
the cerate, or as the cantharidated collodion. If much of this 
drug is absorbed, or if it is administered internally in good 
sized doses, it causes vesical irritation, strangury, and sexual 
excitement. The irritation of the kidneys may be sufficient to 
cause suppression. If taken in concentrated solution it is 
an irritant to the alimentary tract. There is no good reason 
for using cantharides internally. 

CARBO LIGNI— Wood Charcoal 

This substance is prepared from soft wood and occurs as 
a black, tasteless powder. 

Comment. — It has been used externally as an absorbent on 
ulcerating surfaces, but is now rarely used for such purposes. 
Internally it has been used in gastric flatulence, and it may 
absorb some gas, if taken dry or nearly dry. Also, in its 
interstices it may carry enough oxygen into the stomach to be 
mildly antiseptic, but its action is mostly mechanical in brushing 
along mucus that sticks to the gastric mucous membrane. In 
other words, there is very little use for charcoal, and most of 
the preparations offered containing it carry also sodium bicar- 
bonate and carminatives, and a small tablet containing a 



62 THE PRINCIPLES OF THERAPEUTICS 

little charcoal to blacken it can carry no value of charcoal. 

If administered, an average comfortable dose would be 0.50 Gm. 

(7^ grains). 

CASCARA SAGRADA 

Preparations. — Extr actum Cascarce Sagradce; Fluidextr actum 
Co scarce Sagradce; Fluidextr actum Cascarce Sagradce Aroma- 
tic um. 

Comment. — Cascara Sagrada is not used as such; it is used 
only as one of its preparations. It is one of the best laxative 
drugs. It contains a bitter element, and may promote the 
appetite. Large doses are cathartic, but its best use is in 
small doses as a laxative. It is not irritant to the bowels, and 
if regularly administered with a proper diet and plenty of water 
drank and exercise taken, smaller and smaller doses may be 
given, until the constipation is cured. Sometimes it is well to 
give a small dose three times a day, but, generally, it is better 
to give a dose of it after the evening meal or at bedtime, depend- 
ing upon the length of time it takes to act in the individual 
patient. The pleasantest form in which to administer it is in 
the form of the extract, which occurs in powder, and the average 
dose of which is 0.20 Gm. (about 3 grains) administered either 
in tablet or in capsule. The dose of the rluidextract, which 
is very bitter and very disagreeable to take, is 1 mil (15 minims), 
and the dose of the aromatic rluidextract, which is a pleasant 
preparation but contains many more ingredients than is 
needed, is 2 mils (30 minims). 

CERATUM 

Simple cerate contains 30 per cent, of white wax, 70 per cent, 
of benzoinated lard, and has a higher melting point than 
Unguentum. 

CHLORALUM HYDRATUM— Chloral 

Chloral hydrate occurs in colorless crystals, has a caustic, 
nauseating taste, and is very soluble in water. The average 
dose is 0.50 Gm. (7^2 grains). 

Comment. — Chloral hydrate is one of the most efficient 
hypnotics we possess, but it is very disagreeable to take, and 



DRUGS AND PREPARATIONS OF U. S. P. 63 

hence is best ordered in plain water to be administered in 
carbonated water, and followed by a piece of orange, or any- 
other taste the patient desires. 

CHLOROFORMUM 

Preparation. — Spiritus Chloroformi . 

Comments — This anesthetic preparation should be used 
internally only in the form of the spirit, which is a 6 per cent, 
preparation, and the dose is 0.50 mil (7^ minims). Much 
larger doses may be administered, but it is likely to cause 
nausea. Its only action is as a carminative, although it has 
been used in large doses for intestinal worms. 

CHROMII TRIO XIDUM— Chromic Acid 

Chromium trioxide occurs as shining purplish-red crystals, 
which are very soluble in water. It is used externally only, 
best in saturated solution as an escharotic. 

CHRYSAROBINUM 

Chrysarobin is prepared from Goa powder. The official 
preparation is Unguentum Chrysarobini, a 6 per cent, ointment, 
which should generally be diluted. 

Comment. — This preparation is used only in ointments as a 
stimulant and irritant in certain diseases of the skin 

CINCHONA— Calisaya Bark— Yellow Peruvian Bark 

Preparation. — Tinctura Cinchona. 

Comment.' — Cinchona in small doses is a bitter tonic, and is 
best administered as such in the form of the tincture, the dose of 
which is a teaspoonful. Various elixirs of calisaya are on the 
market, and are effective appetizers. 

CINCHONA RUBRA— Red Peruvian Bark 

Comment. — A preparation of this drug, namely, Tinctura 
Cinchona Coniposita, is very much used as a tonic, but as it 
contains serpentaria, which is a useless drug, the mixture seems 
unnecessary. The plain Tincture of Cinchona or an Elixir 
of Calisaya will act as well. 



64 THE PRINCIPLES OF THERAPEUTICS 

dNCHONIDIRE SULPHAS 

Cinchonidine Sulphate (Cinchonidia) occurs as white needles 
or prisms, has a very bitter taste, and is slightly soluble in water. 
The dose is 0.15 Gm. (2K grains). 

Comment. — This alkaloid of cinchona apparently has no 
advantage over the more efficient alkaloid, quinine. 

COCAINA— Cocaine 
COCAINiE HYDROCHLORIDUM 

Cocaine is an alkaloid of Erythroxylon Coca. The hydro- 
chloride of cocaine, the preparation most used, occurs as 
colorless or white prisms or powder, and is very soluble in water. 

Comment. — It is exceedingly rare that cocaine should be 
administered internally; it should only be used for local anes- 
thetic purposes, as the danger of forming a habit is very great. 

CODEINA 

Codeine is an alkaloid of opium. 

Comment. — Codeine is principally used in the form of the 
official Codeines Phosphas or Codeince Sulphas. These salts 
occur as white crystalline powders, both soluble in water, but 
the phosphate the more soluble. For this reason the phosphate 
is the preparation that is best for hypodermic use. The dose of 
each of these salts is 0.03 Gm. {}/% grain) . 

COLCHICI SEMEN 

Comment. — Colchicum seed is best used internally in the 
form of the official Tinctura Colchici Seminis, which represents 
10 per cent, of colchicum, and the dose of which is 2 mils 
(30 minims). The official alkaloid of colchicum is Colchicina, 
which occurs as pale yellow scales or powder. It is soluble in 
water, and the average dose is 0.0005 Gm. (K20 grain). 

COLLODIUM 

Comment. — Collodion is a solution of gun cotton in ether, 
and is used as a protective. The official Collodium Cantharida- 
turn contains cantharides, and is used to cause blistering, and 






DRUGS AND PREPARATIONS OF U. S. P. 65 

the official Collodium Flexible contains castor oil to prevent it 
contracting the tissues to which it is applied. 

COTARNINE HYDROCHLORIDUM— Stypticin 

Cotarnine hydrochloride is prepared from the narcotine of 
opium, and occurs as a yellow crystalline powder, very soluble 
in water. The average dose is 0.06 Gm. (1 grain). 

Comment. — Cotarnine Hydrochloride acts like hydrastinine 
as a contractor of the uterus. 

CREOSOTUM 

Creosote is a mixture of phenols and phenol derivatives, and 
acts like phenol. 

Comment. — Creosote has been used internally for pulmonary 
tuberculosis, for laryngeal tuberculosis by inhalation, and was 
an ingredient of many mixtures used for influenza. However, 
it is of doubtful value when administered internally, though by 
inhalation it is of local value. When the doses are increased 
and the drug is pushed it causes indigestion and disturbance of 
the pancreas. The average dose is 0.10 mils (ij^ minims). 

CRESOL 

Cresol is a mixture obtained from coal-tar. 
Preparation. —Liquor Cresolis Compositus. 
Comment. — Cresol and its official preparation are used for 
antiseptic purposes. There is no use for cresol internally. 

CRETA PR^PARATA— Prepared Chalk 

Prepared chalk occurs as a grayish-white powder, insoluble in 
water. 

Preparations. — Mistura Cretce (Chalk Mixture), the dose of 
which is 2 teaspoonfuls. 

Comment. — Prepared chalk is a mild antacid used in tooth 
pastes and as a dusting powder. Chalk Mixture has largely 
been used for children with acid indigestion and with diarrhea, 
but Milk of Magnesia is better for this purpose. Internally 
the dose of prepared chalk is too large for comfort. 



66 THE PRINCIPLES OF THERAPEUTICS 

CUBEBA— Cubebs 

Comment. — There is no use for cubebs except in the form of 
the official Trochisci Cubebce which is made from the official 
Oleoresina Cubebce. The dose is one troche as needed to cause 
increased secretions of the membranes of the mouth, throat and 

larynx. 

CUPRI SULPHAS— Blue Vitriol— Bluestone 

Copper Sulphate occurs as deep blue crystals, very soluble in 
water. 

Comment. — Copper sulphate is not used internally except as 
an emetic. The dose as an emetic should be 0.50 Gm. (7^ 
grains) dissolved in water. This dose should not be repeated. 
Externally it is used in the form of the solid stick (bluestone) 
as an escharotic, especially on granular eye-lids. 

DIACETYLMORPHLN^ HYDROCHLORIDUM— Heroin 

Diacetylmorphine is prepared from morphine by acetyliza- 
tion. The hydrochloride, heroin, occurs as a white crystalline 
powder, very soluble in water. The average dose is 0.003 Gm. 
(Ho grain). 

Comment. — Heroin has no advantage over codeine in quieting 
cough, although it is cheaper. It is a very subtle habit-forming 
drug, hence should not be used. 

DIASTASUM 

Diastase is a mixture containing amylolytic enzymes obtained 
from an infusion of malt, and occurs as a yellowish-white 
powder, soluble in water. The average dose is 0.50 Gm. (7H 
grains) . 

Comment. — Diastase will not have amylolytic action in the 
stomach after acid peptones have been formed, or after free 
hydrochloric acid is present. Various malt diastatic prepara- 
tions can be obtained, and are used in preparing milk for feed- 
ing infants. 

DIGITALIS— Foxglove 

Digitalis occurs as dried leaves, and the average dose is 
0.06 Gm. (1 grain). 



DRUGS AND PREPARATIONS OF U. S. P. 67 

Preparations. — Fluidextr actum Digitalis, average dose 2 drops 
(about 1 minim). Infusum Digitalis, average dose a teaspoon- 
ful. Tinctura Digitalis, represents 10 per cent, of the drug, 
average dose 0.50 mil (7^ minims). 

Comment. — Soluble tablets made of digitalis each represent- 
ing 1 grain are very efficient. The infusion of digitalis must be 
freshly prepared, and a teaspoonful of this preparation represents 
a little more than 1 grain, namely 0.075 Gm. This preparation, 
long thought to have better action than other preparations of 
digitalis, has such activity probably because a larger dose is 
generally given. Also, an old tincture will lose its strength, 
and therefore cannot be compared with a freshly made infusion. 
All preparations of digitalis deteriorate, except the properly 
prepared and properly cared for leaves. 0.50 mil of the 
tincture represents 0.05 Gm. of the drug, a little less than 1 
grain. 

ELATERINUM 

Elaterin is a principle obtained from elaterium, and occurs 
as small white crystals. 

Preparation. — Trituratio Elaterini. This preparation repre- 
sents 10 per cent, of elaterin, and the average dose is 0.03 Gm. 
(H grain). 

Comment. — Elaterin is best used in the form of the triturate. 
It is a very active purgative, producing watery stools, followed 
by more or less prostration. The excuse for using this drug is 
uremia, and occasionally dropsy due to insufficiency of the kid- 
neys. A weak circulation would contraindicate the use of this 
drug. 

ELIXIR AROMATICUM 

Comment. — This is a very pleasant aromatic menstruum 
containing orange, lemon, coriander, anise, syrup and alcohol. 

ELIXIR GLYCYRRHIZJE 

Comment. — This preparation of licorice is used as a menstruum 
for administering disagreeable drugs, but it should be urged that 
sweets and syrups tend to aggravate a bad taste by prolonging 
it. Also, sweets destroy the appetite. 



6S THE PRINCIPLES OF THERAPEUTICS 

EMETINE HYDROCHLORIDUM 

The hydrochloride of the alkaloid emetine obtained from 
ipecac occurs as a white or yellowish crystalline powder, soluble 
in water. It is used mostly hypodermatically. The average 
dose is 0.02 Gm. (}£ grain). 

Comment. — This drug is used as a specific in amebic dysen- 
tery. 

ERGOTA— Ergot of Rye 

Ergot is a fungus, and occurs as a brownish-black substance, 
having a disagreeable taste. 

Preparations. — Extractum Ergola, the average dose of which 
is 0.25 Gm. (4 grains); Fluid extractum Ergotcz, the average 
dose of which is 2 mils (30 minims). 

Comment. — Ergot is used only in the form of its preparations. 
Ergo tine is a name for a pure extract of ergot. 

EUCALYPTOL 

Eucalyptol is obtained from the volatile oil of Eucalyptus 
Globulus, and occurs as a colorless liquid having an aromatic 
camphoraceous odor. 

Comment. — Eucalyptol is mildly antiseptic, and is added to 
many sprays and gargles for mild antiseptic and stimulant 
action. 

FEL BOVIS 

Oxgall is prepared from the fresh bile of the ox. 

Preparation. — Extractum Fellis Bovis. This occurs as a 
powdered extract. The average dose is 0.10 Gm. (ij^ grains). 

Comment. — Oxgall is used as a mild laxative, and for this 
purpose is often added to laxative drugs. 

FERRUM 

Valuable preparations of iron are: 

FERRI CARBONAS SACCHARATUS 

The average dose of saccharated ferrous carbonate is 0.25 
Gm. (4 grains). 



DRUGS AND PREPARATIONS OF U. S. P. 69 

FERRI HYDROXIDUM CUM MAGNESII OXIDO 

This is the arsenic antidote, and is kept ready for immedi- 
ate preparation in the case of arsenic poisoning. The dose is 
100 mils (about 3^ fluid ounces). 

FERRI PHOSPHAS 

This preparation is soluble in water. The average dose is 
0.25 Gm. (4 grains). 

FERRI SULPHAS 

This astringent salt and its preparations are used externally 
only. * 

Comment. — A long used mixture of ferrous carbonate, 
officially Massa Ferri Carbonatis (Vallet's Mass), prepared 
from ferrous sulphate, and with honey, sugar, and syrup, is not 
needed in medicine. 

FERRUM REDUCTUM— Reduced Iron— Quevenne's Iron 

Reduced iron occurs as a fine grayish-black powder, slightly 
astringent, and the average dose is 0.06 Gm. (1 grain). 

GLUCOSUM 

Glucose occurs as a thick, syrupy liquid, and is obtained 
by the incomplete hydrolysis of starch, and consists chiefly of 
dextrose and dextrins. 

GLYCERINUM 

Glycerin occurs as a clear colorless liquid, of a thick, syrupy 
consistence. The average dose is a teaspoonful. 

Preparation. — Suppositoria Glycerini. Each suppository con- 
tains 3 Gms. of glycerin. 

Comment. — Glycerin is a mild antiseptic, and in full strength 
is irritant to many skins, and to some skins is irritant even if 
well diluted. A 25 per cent, solution in water, or in perfumed 
water, is the strength of preparation generally advisable for 
external use. Internally glycerin is sometimes used as a 
laxative. 



70 THE PRINCIPLES OF THERAPEUTICS 

GLYCYRRHIZA 

Preparations. — Extractum Glycyrrhizce occurs in the form of 
stick licorice used for solution in the mouth to soothe irritation 
and cough. It is used in the preparation of the official ammon- 
ium chloride and cubeb troches. Mistura Glycyrrhiz<z Com- 
posita (Brown Mixture). This is a multiple mixture containing 
licorice, syrup, acacia, tartar emetic, paregoric, and sweet 
spirits of nitre. It represents pharmacal nonsense, and though 
ancient and honorable should be relegated to the past and 
shelved as an exhibit of the tolerance of the human stomach. 
Puhis Glycyrrhizce Compositus, Compound Licorice Powder. 
This much used laxative mixture contains 23 per cent, of 
licorice, 18 per cent, of senna, and 8 per cent, of washed sulphur. 
The average dose as a laxative is 4 Gm. (1 drachm). 

Comment. — Licorice is a soothing, demulcent laxative, is 
sickish sweet in the form of the syrups, is likely to upset the 
stomach, and has no great activity except that it is pleasant to 
take. It is doubtful if the licorice adds any efficiency to the 
Compound Licorice Powder; it would be better named if it 
were called compound senna, or compound sulphur, powder. 

GR AN ATUM— Po megra na te 

Preparation. — Fluidextt -actum Granati, the average dose of 
which is 2 mils (30 minims). 

Comment. — Pomegranate is used only as an anthelmintic 
against tapeworms. The best preparation is the fluidextract. 

HEXAMETHYL EN AMINA— Hcxamethylcne -tetramine 

Hexamethylenamine is a condensation product of ammonia 
and formaldehyde, and occurs as colorless crystals or as a white 
powder. It is very soluble in water. 

Comment. — Uro tropin is used as a urinary antiseptic. It 
has not been shown that it has any antiseptic value except in 
acid media, therefore it cannot have germicidal activity in the 
alkaline fluids of the body. The average dose is 0.50 Gm. 
(7M grains). It should be taken dissolved in from one-half 
to a glass of water. The frequency of the dose should be three 
or four times in twenty-four hours. 



DRUGS AND PREPARATIONS OF U. S. P. 71 

HOM ATROPINE HYDROBROMIDUM 

The hydrobromide of homatropine, an alkaloid obtained by 
the condensation of tropine and mandelic acid, occurs as a 
white crystalline powder, soluble in water. 

Comment. — This is used externally only, to dilate the pupils. 

HYDRARGYRUM— Mercury— Quicksilver 

Mercury is used in some preparation, as Massa Hydrargyri 
(Blue Mass, Blue Pill), the average dose of which is 0.25 Gm. 
(4 grains). Other preparations are, Unguentum Hydrargyri, 
and Unguentum Hydrargyri Dilutum (Blue Ointment). 

Comment. — Blue Mass (Blue Pill) is another ancient and 
honorable, and at times dishonorable, preparation. It should be 
relegated to the scrap heap. It has no advantage over calomel. 

HYDRARGYRI CHLORIDUM CORROSIVUM— Corrosive 

Sublimate — Mercuric Chloride 

The bichloride of mercury occurs in crystalline masses or as 
a white powder, soluble in water. The average dose is 0.003 
Gm. (}io grain). 

Preparation. — Toxitabellce Hydrargyri Chloridi Corrosivi, 
poison tablets of corrosive sublimate, for use in solutions as an 
external antiseptic. 

HYDRARGYRI CHLORIDUM MITE— Mercurous Chloride— 
Subchloride of Mercury — Calomel 

Calomel occurs as a white impalpable powder. The average 
dose for systemic action is 0.015 Gm. (}i grain). 

Comment. — Calomel is mostly used as a purgative, generally 
best combined with bicarbonate of sodium. The average dose 
is o. 10 Gm. (1 Y 2 grains) . A larger dose may be given, if desired. 
It is rarely advisable to give minute doses, as }{ of a grain, 
every half hour or hour. Calomel occurs in that medieval 
preparation termed the Compound Cathartic Pill. 

HYDRARGYRI IODIDUM FLAVUM— Protoiodide of Mercury- 
Yellow Iodide of Mercury 

Yellow mercurous iodide occurs as a bright yellow amorphous 
powder, insoluble in water. The average dose is 0.01 Gm. 
(H grain). 



72 THE PRINCIPLES OF THERAPEUTICS 

HYDRARGYRI IODIDUM RUBRUM— Biniodide of Mercury- 
Red Iodide of Mercury 

Red mercuric iodide occurs as a scarlet red amorphous pow- 
der, insoluble in water. The average dose is 0.003 Gm. (34 

grain). 

HYDRARGYRI OXIDUM FLAVUM 

Yellow mercuric oxide occurs as a light orange-yellow amor- 
phous powder, insoluble in water. 

Preparation. — Unguentum Hydrargyri Oxidi Flam. This is a 
10 per cent, ointment of yellow oxide of mercury. 

Comments — Yellow oxide of mercury is not used internally, 
It is sometimes used externally as a powder on syphilitic sores, 
diluted with an equal amount of some inert powder. The oint- 
ment is frequently used externally. 

HYDRARGYRI OXIDUM RUBRUM— Red Precipitate 

Red mercuric oxide occurs as a heavy orange-red crystalline 
powder, insoluble in water. 

Comment. — This preparation is not used internally. It may 
be used externally for syphilitic sores when diluted with an equal 
amount of some inert powder. 

HYDRARGYRI SALICYLAS 

Mercuric salicylate is a compound of mercury and salicylic 
acid, and occurs as a yellowish or pinkish powder, practically 
insoluble in water. The average dose is 0.004 Gm. (34 5 grain). 

Comment. — This preparation is principally used for intra- 
muscular injections, and is given in oil suspension. 

HYDRARGYRUM AMMONIATUM— White Precipitate 

Ammoniated mercury occurs as a white amorphous powder, 
insoluble in water, and is used mostly in the form of its prepara- 
tion, Unguentum Hydrargyri Ammoniati, which is a 10 per cent, 
preparation of this salt. 

HYDRASTINiE HYDROCHLORIDUM 

Hydrastine hydrochloride is a preparation of the alkaloid 
hydrastine which is obtained from hydrastis or prepared syn- 



DRUGS AND PREPARATIONS OF U. S. P. 73 

thetically. It occurs as a white powder, very soluble in water. 
The average dose is o.oi Gm. (}£ grain). 

Comment. — This preparation causes uterine contraction and 
is used for uterine hemorrhage. 

HYDRASTINENLK HYDROCHLORIDUM 

The hydrochloride of hydrastinine is an alkaloid obtained by 
the oxidation of hydrastine, and occurs as light yellowish 
needles or crystalline powder, very soluble in water and alcohol. 
The average dose is 0.03 Gm. {}^ grain). 

Comment. — This preparation is active as a contractor of the 
uterus, and raises the general blood-pressure, but it may cause 
serious depression. 

HYPOPHYSIS SICCA— Desiccated Pituitary Body 

Desiccated hypophysis is prepared from the posterior lobe of 
the pituitary body of cattle, and occurs as a yellowish powder, 
only partially soluble in water. The average dose is 0.03 Gm. 
(}i grain). 

IODOFORMUM 

Iodoform occurs as a lemon-yellow powder. 

Comment. — It has no use internally. It is only a mild 
antiseptic externally, and it is inexcusable to use it externally or 
in any orifice of the body on account of its odor. In oil emul- 
sion it has been used with some success as an injection into 
tuberculous joints and tendons. It can cause poisoning when 
used over large absorbing surfaces or in the cavities of the body, 
and the poisoning is similar to that of phenol. Its antiseptic 
value is supposed to be due to its liberation of iodine. 

IODUM 

Iodine occurs in bluish-black plates, has a distinctive odor, 
and is practically insoluble in water, soluble in alcohol. 

Preparations. — Liquor Iodi Compositus (Lugol's Solution), 
which is used as a mild antiseptic astringent and stimulant to 
mucous membranes. It is generally combined with a small 
amount of glycerin, and swabbed on the part to be treated. 
Tinctura Iodi is a 7 per cent, alcoholic preparation of iodine. 



74 THE PRINCIPLES OF THERAPEUTICS 

It is largely used as an antiseptic and germicide and also as a 
counterirritant. It may be used internally in the dose of i 
drop. Unguentum Iodi contains 4 per cent, of iodine. It is 
used as a mild counterirritant. 

IPECACUANHA 

Ipecac occurs as the dried root. 

Preparations. — Fluidextr actum Ipecacuanha, the average 
expectorant dose of which is about 1 drop. Puhis Ipecacuanha 
et Opii (Dover's Powder) contains 10 per cent, of ipecac. 
Syrupus Ipecacuanha contains 7 per cent, of the fluidextract. 
The expectorant dose is 0.50 mil (7^ minims), given every two 
hours. The emetic dose is a tablespoonful. 

Comment. — Powdered ipecac root is rarely used internally 
except as an emetic, and the emetic dose is 2 Gm. (30 grains). 

JALAPA 

Preparation. — Puhis Jalapce Compositus contains 35 per 
cent, of jalap and 65 per cent, of potassium bitartrate. The 
average dose is 2 Gm. (30 grains). 

Comment. — Jalap is an active purgative, causing watery 
movements in three to four hours. It is best not used as such, 
but preferably as the compound jalap powder. The resin of 
jalap has been used in the compound cathartic pill, but neither 
this preparation nor the compound cathartic pill is needed 
in medicine. 

LINIMENTUM CALCIS— Carron Oil 

Comment. — This preparation contains equal parts of lime 
water and linseed oil, which should be freshly combined. It 
has long been used for burns. It was named carron oil from 
the Carron Iron Works of England where burns frequently 
occurred. This liniment is non-irritant and soothing. 

LINIMENTUM CAMPHORS— Camphorated Oil 

Comment. — This preparation contains 20 per cent, of cam- 
phor in cottonseed oil. It is a mild stimulant to the skin. 



DRUGS AND PREPARATIONS OF U. S. P. 75 

LINIMENTUM CHLOROFORMI 

Comment. — This preparation contains 30 per cent, of chloro- 
form in 70 per cent, of soap liniment, and is mildly counter- 
irritant. 

LINIMENTUM SAPONIS 

Soap liniment contains camphor and alcohol, and is mildly 
counterirritant. 

LINIMENTUM SAPONIS MOLLIS 

Comment. — Soft soap liniment contains 65 per cent, of soft 
soap (cottonseed oil soap) and is used for cleansing purposes 
and for shampoos. It is strongly alkaline. 

LINIMENTUM TEREBINTHINiE— Kentish's Ointment 
This is an irritant ointment. 

LIQUOR FORMALDEHYDI 

Solution of formaldehyde occurs as a clear colorless liquid, 
and is used as a disinfectant and antiseptic. It is very irritant, 
and its vapor is irritant to mucous membranes. 

LIQUOR HYDROGENII DIOXIDI 

This solution of peroxide of hydrogen contains not less 
than 3 per cent, of H 2 2 . It should be kept in a cool place and 
protected from light; it should be colorless. 

Comment. — When this solution deteriorates it becomes 
irritant and should not be used either externally or internally. 
It is rarely used internally, but may be used in certain conditions 
of the stomach in teaspoonful doses, well diluted. 

LYCOPODIUM 

Lycopodium is a yellow dusting powder, used for protective 
purposes on the skin. 

MAGMA MAGNESIA 

Milk of magnesia occurs as a white liquid containing magne- 
sium hydroxide in suspension. The average dose is 2 teaspoon- 
fuls. 



7 6 THE PRINCIPLES OF THERAPEUTICS 

Comment. — This is a very bland antacid, soothing to mucous 
membranes and is mildly laxative. It is used as a laxative 
for infants and children, and is often added to the artificial 
foods of infants. It is of value in ulcer of the stomach and as an 
alkaline mouth wash. 

MAGNESII CARBONAS 

Magnesium carbonate occurs as a light, white powder, insolu- 
ble in water. 

Comment. — Magnesium carbonate is an antacid, but is not 
as useful as magnesium oxide, as it causes more gas, and the 
dose is too large for comfort. 

MAGNESII OXIDUM — Magnesia — Calcined Magnesia — Light 

Magnesia 

Magnesium oxide occurs as a white, fine powder, insoluble 
in water. 

Comment. — This preparation is an antacid and a mild 
laxative. It must be given in powder, and the average dose is 
i Gm. (15 grains). 

MAGNESII SULPHAS— Epsom Salt 

Magnesium sulphate occurs as small needles or prisms, has a 
bitter taste, and is very soluble in water. The average dose 
is 15 Gm. (about 4 drachms). 

Comment. — Epsom salt is a bland, effective, and rapidly 
acting saline purgative. It is usually administered before 
breakfast and in hot water. To cause depletion and to cause 
absorption of extravasated fluids it should be given in concen- 
trated solution. 

MANGANI DIOXIDUM PR^CIPITATUM 

Precipitated manganese dioxide occurs as a heavy black 
powder, insoluble in water. The average dose is 0.25 Gm. 
(4 grains). 

Comments — This drug is used only as a stimulant to the 
menstrual flow in delayed or scanty menstruation. For this 
purpose it should be given a few days before the time for men- 
struation to begin. It should not be used when pregnancy is 



DRUGS AND PREPARATIONS OF U. S. P. 77 

suspected, as it may cause abortion. It is best given in capsules 
or in soluble tablets. 

MENTHOL 

Menthol occurs as white crystals, only slightly soluble in 
water, very soluble in alcohol. 

Comment. — Menthol is mildly stimulant if rubbed on the 
skin, and causes a cooling sensation if it is allowed to evaporate. 
Menthol pencils are often used on the skin also menthol lini- 
ments and ointments. Menthol is added to sprays, mouth 
washes and gargles for its stimulating effect on mucous mem- 
branes, but it is irritant if used in too strong solutions. The 
vapor from menthol pencils is often inhaled in coryza. 

There is no use for menthol internally; other preparations 
of peppermint are better. 

METHYLIS SALICYLAS— Oil of Wintergreen— Oil of Beta!— 
Oil of Sweet Birch 

Methyl salicylate is made synthetically or is distilled from 
wintergreen or birch, and the label should indicate by which 
method the preparation is made. It occurs as a yellowish 
liquid, with the smell an 1 taste of wintergreen. 

Comment. — The action of methyl salicylate is similar to 
salicylic acid. It is used mostly externally as a liniment. If 
administered internally the average dose is about 0.5 mil 
(7^ minims). It should be given in emulsion or in ready 
prepared oil of wintergreen capsules, and should be taken well 
diluted and not on an empty stomach. 

METHYLTHIONINiE CHLORIDUM— Methylene Blue 

Methylene Blue occurs as a dark green crystalline powder, 
soluble in water. 

Comment. — This preparation is of value in malarial fever 
when quinine is not tolerated. The average dose is 0.10 Gm. 
(i}i grains) in capsules, taken with plenty of water, and 
administered every three hours. This drug has also been 
used in gonorrhea, and in infections of the bladder and pelvis 
of the kidney. The dose in this case is 0.10 Gm. (i^ grains), 
in capsules, every six hours. The urine will become green or 



;S THE PRINCIPLES OF THERAPEUTICS 

bluish-green after the administration of methylene blue. The 
over-action of this drug is shown by nausea, vomiting, backache, 
frequent urination, perhaps strangury, and general depression. 

MORPHINA 

This alkaloid of opium is mostly used in the form of one of 

its salts. 

MORPHINE HYDROCHLORIDUM AND MORPHINE SULPHAS 

These salts are soluble in water. The average dose is 

0.008 Gm. (}i grain). 

NUX VOMICA 

Comment. — The best preparation is Tinctura Nucis Vomica, 
which contains 10 per cent, of the drug. As the alkaloid 
strychnine represents all the activity desired of nux vomica, 
when strychnine action is needed salts of the alkaloid should 
be used. Therefore the only use for the tincture of nux vomica 
is as a stimulating bitter tonic, and the average dose is from 
1 to 5 drops, in water, before meals. 

OLEUM CADINUM 

Oil of cade occurs as a dark, brown, thick, tarry liquid, in- 
soluble in water. 

Comment. — This oil is used externally as a stimulant to 
the skin, best diluted with an oil or ointment to 25 to 50 per 
cent, strength. 

OLEUM CARYOPHYLLI— Oil of Cloves 

Comment.- — Oil of cloves is very valuable as a local sedative 
in tooth cavities or in cavities in the jaw made after extraction 
of teeth. 

OLEUM CASSLE— Oil of Cinnamon 

Preparation. — Aqua Cinnamomi. 

Comment. — The water of cinnamon is a very pleasant 
menstruum. 

OLEUM CHENOPODII— American Wormseed Oil 

This preparation is a volatile oil distilled from wormseed, 
occurs as a yellowish liquid, and has a disagreeable odor and 
taste. 



DRUGS AND PREPARATIONS OF U. S. P. 79 

Comment. — Wormseed oil is a very valuable anthelmintic 
both for roundworms and for hookworms. The proper dose 
and the method of administration depends on the age of the 
patient and the parasite to be removed. 

OLEUM EUCALYPTI 

Comment. — Eucalyptus oil has no special internal use. It is 
used in gargles and sprays. 

OLEUM GOSSYPII SEMINIS— Cottonseed Oil 

Comment.- — This is a fixed oil, and is as valuable for external 
use as the more expensive olive oil. 

OLEUM JUNIPERI— Oil of Juniper Berries 

Oil of juniper is a volatile oil distilled from the juniper fruit. 
The average dose is 0.2 mil (3 minims). 

Preparations. — Spiritus Juniperi, the average dose of which 
is 2 mils (30 minims), and Spiritus Juniperi Compositus, the 
average dose of which is 2 teaspoonfuls. 

Comments — Juniper is a mild diuretic, and the compound 
spirit which contains besides juniper, caraway and fennel, 
acts not unlike gin. 

• OLEUM LAVANDULAE— Oil of Lavender 

Comment. — Lavender has no medicinal value. The official 
tincture, Tinctura Lavandula Compositus, which contains 
besides lavender, rosemary, cinnamon, clove, nutmeg, and 
red saunders, is a carminative, and, on account of its alcohol, 
at times has a pleasant, soothing effect. 

OLEUM LINI— Linseed Oil— Oil of Flaxseed 

Comment. — This is a fixed oil which is principally used 
externally. 

OLEUM MENTHA PIPERITA— Oil of Peppermint 

This is a volatile oil used principally in one of its preparations 
as a pleasant menstruum or as a carminative. 



So THE PRINCIPLES OF THERAPEUTICS 

Preparations. — Aqua Mentha Piperita; Spiritus Mentha 
Pi peri tee. The average dose of the spirit is 2 mils (30 minims). 

OLEUM MORRHILE— Cod Liver Oil 

Comment. — This preparation is a fixed, pale yellow, thin oil, 

and has a fishy taste. It is one of the most easily digestable of 

oils, and contains a valuable vitamine, and hence is a food. 

Emulsions of cod liver oil are really not needed, as they furnish 

less of the oil and are often not better tolerated than a small 

dose of the pure oil. It may be taken in ready prepared flexible 

capsules, or it may be given on salt and water, or on coffee. An 

average dose is from one-half to one teaspoonful, three times a 

day, after meals. In the summer it should be kept cold, 

as it deteriorates. Cod liver oil may also be rubbed into the 

skin. 

OLEUM OLIV.E — Sweet Oil 

This is a fixed oil obtained from ripe olives. 

Comment. — Olive oil is used mostly externally, but may be 
given as a laxative both to children and adults. The adult 
dose as a laxative would be about 2 tablespoonfuls. As a food, 
butter, cream, and cod liver oil are better. 

OLEUM PICIS LIQUIDJE RECTIFICATUM— Rectified Oil of Tar 

Comment. — This is used as a stimulant added to ointments 
in the treatment of skin diseases. 

OLEUM PINI PUMILIONIS— Oil of Pine Needles 

Comment. — This volatile oil is added to solutions for inhala- 
tion or for sprays. 

OLEUM RICINI— Castor Oil 

This is a fixed oil of pale yellow color, and has a nauseating 
taste. The average dose is a tablespoonful. 

Comment. — Castor oil is one of the best of the purgatives. 
It is non-irritant, and acts in four or five hours. It is excreted 
in the milk, hence should not ordinarily be administered to 
nursing women. It should not be used as a laxative, as consti- 
pation follows its action. It may be administered in flexible 



DRUGS AND PREPARATIONS OF U. S. P. 8l 

capsules, or on salt and water, on coffee, or in flavored effervesc- 
ing mixtures. 

OLEUM S ANT ALI— Oil of Sandalwood 

This is a volatile oil distilled from sandalwood, and occurs 
as a pale yellow, somewhat thick liquid, with the odor and taste 
of sandalwood. 

Comment. — Oil of santal is a most useful stimulant antiseptic 
to the urinary organs. It gives its odor to the urine and to the 
breath. In large doses it may cause backache in the lumbar 
region and uretal pains. It has also been used as an expecto- 
rant in bronchitis. It is best administered in the form of 
flexible capsules, and the dose is 0.30 to 0.60 mils (5 to 10 minims) 
taken with plenty of water three or four times a day, best after 

OLEUM SESAMI— Teel Oil— Bcnne Oil 

Comment. — This is a fixed bland oil for external use. 

OLEUM TEREBINTHDSLaE— "Spirits of Turpentine" 

Comment. — This volatile oil occurs as a colorless liquid, 
and is used externally for its rubefacient action on the skin, 
mostly for stupes. 

OLEUM TEREBINTHIRE RECTIFICATUM 

Comment. — This colorless liquid is used externally for 
stimulating liniments, and on stupes, for its counterirritant 
effect. It has been used internally as a carminative, but such 
treatment is not often advisable. Like volatile oils, it is a 
slight cardiac and cerebral stimulant, but if much is given it 
will irritate the kidneys and bladder, and may cause strangury 
and suppression. If used internally, the average dose is 0.30 
mil (5 minims), given in emulsion. 

OLEUM THEOBROMATIS— Cacao Butter 
Comment. — This is a bland, non-irritating, solid fixed oil, 
used for making suppositories and for massage. 

OLEUM TIGLII— Croton Oil 

This is a fixed oil of a yellowish-brown color. The average 
dose is one or two drops. 



82 THE PRINCIPLES OF THERAPEUTICS 

Comment. — This is an active irritant purgative, and has no 
other use. It acts in from one to two hours. Overactionis 
evidenced by severe purging, colic, enteritis and prostration. 
Formerly it was much used as a counterirritant painted over 
the skin, especially of the chest, to cause pustulation. It is 
best administered on the tongue, one or two drops on a tea- 
spoonful of granulated sugar. 

OPII PULVIS 

Powdered opium is light brown in color. The average dose is 
0.06 Gm. (1 grain). 

Preparations. — Opium Deodoratum, the average dose of which 
is 0.06 Gm. (1 grain). This preparation is opium with its 
narcotine removed, hence is thought to have less active effect 
on the brain in children. Pulvis Ipecacuanha et Opii (Dover's 
Powder). This preparation contains 10 per cent, each of 
ipecac and powdered opium. The average dose is 0.50 Gm. 
(7^ grains). Tinctura Opii Camphor ata (Paregoric). This 
preparation contains 0.4 per cent, each of powdered opium, 
benzoic acid and camphor. The average dose is a teaspoonful. 

OPIUM 

Opium is the milky exudate of Papaver somniferum. 
Preparations. — Extractum Opii is a powdered extract of 
opium, and the average dose is 0.03 Gm. (J-£ grain). 

OPIUM GRANULATUM— Granulated Opium 

Preparations. — Tinctura Opii (Laudanum). This prepara- 
tion represents 10 per cent, of the drug, and the average dose is 
0.50 mil (7^ minims). Tinctura Opii Deodorati. This 
preparation represents 10 per cent, of the drug, and the average 
dose is 0.50 mil (j% minims). 

PANCREATINUM 

Pancreatin contains enzymes, principally amylopsin, trypsin 
and steapsin, and is prepared from the fresh pancreas of the hog 
or ox. It occurs as a cream colored amorphous powder. The 
average dose is 0.50 Gm. (7% grains). 



DRUGS AND PREPARATIONS OF U. S. P. 83 

Comment. — Pancreatin is a digestant, but it does not well act 
in the stomach except before acid peptones in any amount have 
been formed and before free hydrochloric acid appears. It has 
been thought that it was rendered inert by the acid of the stom- 
ach. It has, however, lately been shown that it may become 
again active when it reaches the alkaline intestines. Pancreatin 
acts only in alkaline media, consequently it is generally com- 
bined with sodium bicarbonate. The best use for pancreatin 
is as a predigestant of milk or other food before it is taken. It 
is best administered as a powder. 

P AR AFORM ALDEH YDUM— Paraf or m 

Paraformaldehyde occurs in white masses or powder, and has 
a slight odor of formaldehyde. 

Comment. — This preparation has strong antiseptic properties 
and also is somewhat escharotic, and is used for warts and 
callous skin. When heated it liberates formaldehyde gas. It 
should not be used internally. 

PARALDEHYDUM 

Paraldehyde occurs as a colorless liquid, and has a pungent 
odor and a burning taste. The average dose is % a teaspoonful. 

Comment. — This pungent preparation is best administered 
on cracked ice and water. 

PELLETIERIRE TANNAS 

Pelletierine Tannate occurs as a yellowish powder, practically 
insoluble in water, and the average dose is 0.25 Gm. (4 grains). 

Comment. — This drug is used as an anthelmintic especially 
against tenia. 

PEPSINUM 

Pepsin is a mixture containing a proteolytic ferment or en- 
zyme obtained from the fresh stomach of the hog. It occurs 
as yellowish scales or powder. The average dose is 0.50 Gm. 
(-7-56 grains). 

Comment. — Pepsin is an aid to stomach digestion. It should 
be given after meals, and is most active when combined with 



84 THE PRINCIPLES OF THERAPEUTICS 

dilute hydrochloric acid. Pepsin is not often needed in the 
stomach. Dilute hydrochloric acid generally is sufficient. 

PETROLATUM 

Petroleum jelly is a purified mixture of semisolid hydro- 
carbons and is obtained from petroleum. It occurs in the form 
of a yellowish ointment. 

Preparations. — Petrolatum Album (White Petroleum Jelly); 
Petrolatum Liquidum (Mineral Oil). 

Comment. — Petroleum does not mix with water, thus differ- 
ing from wool fat. It does not become rancid, and while not 
germicidal, still will not promote, but rather inhibits, bacterial 
growth. The above preparations are bland and protective, 
but are not absorbed by the skin or mucous membranes. 
Mineral oil is much used as a laxative. A tablespoonful is a 
small dose. 

PHENOL— Carbolic Acid 

Phenol is obtained from coal-tar or made synthetically, and 
occurs in colorless crystals or as a white crystalline mass, and is 
soluble in water. 

Preparations. — Glyceritum Phenolis is a preparation containing 
20 parts of liquefied phenol and 80 parts of glycerin. Phenol 
Liquef actum is a colorless liquid containing not less than 87 
per cent, of phenol. Unguentum Phenolis is an ointment con- 
taining 2^i per cent, of phenol. 

Comment. — There is no internal use for phenol. 

PHENOLPHTHALEINUM 

Phenolphthalein occurs as a yellowish-white crystalline 
powder, is tasteless, and is soluble in water. The average dose 
is 0.15 Gm. (2^ grains). 

Comment. — Solutions of this salt are injected hypodermati- 
cally as a test of kidney efficiency. It is also largely used as a 
laxative, generally given at bedtime, and is pleasant for children 
to take, as it is tasteless, and, when combined with sugar of 
milk in a tablet, is similar to candy. The tablet should be well 
chewed or crushed. This preparation should not be used too 
long, as it tends to irritate the lower bowel. 



DRUGS AND PREPARATIONS OF U. S. P. 85 

PHENYLIS SALICYLATE— Salol 

Phenyl salicylate occurs as a white crystalline powder, has an 
aromatic odor, a characteristic taste, and is insoluble in water. 
The average dose is 0.30 Gm. (5 grains). 

Comment. — Salol is a valuable bowel antiseptic and causes 
constipation. It is also a valuable urinary antiseptic. Over- 
doses cause phenol poisoning. It is best administered in 
powder or capsule. 

PHYSOSTIGMINE SALICYLAS— Eserine Salicylate 

Physostigmine is an alkaloid of calabar bean, and the salicy- 
late occurs as yellowish crystals, not very soluble in water. 

Comment. — Physostigmine salicylate is mostly used locally 
in ophthalmology to cause contraction of the pupil. It has 
been used hypodermatically to increase peristalsis in paresis of 
the intestines after laparotomy or from other cause. It is some- 
times successful, but ergot, atropine and pituitary extracts are 
better. Poisoning from this drug is that of depression of the 
nervous and circulatory systems. There is no internal use for 
physostigmine. If used for action on the intestines it should 
be given hypodermatically. 

PILOCARPUS— Jafeorandi 

Comment. — Pilocarpus is not used as such. It may be used 
in the form of its fluidextract, Fluidextr actum Pilocarpi, the 
dose of which is 2 mils (30 minims) . Pilocarpus is most used 
in the form of its alkaloid. 

PILOCARPINE HYDROCHLORIDUM 

Pilocarpine is an alkaloid obtained from pilocarpus, and the 
hydrochloride occurs as colorless crystals, very soluble in water 
and alcohol. 

Comment. — This preparation is used to cause perspiration, 
and for this purpose is generally given hypodermatically. The 
average dose is 0.005 Gm. (K2 grain) . There is no good use for 
pilocarpine internally. 

PLUMBI ACET AS— Sugar of Lead 

Lead acetate occurs as crystalline masses or granular crystals, 
has a sweetish, astringent taste, and is very soluble in water. 



86 THE PRINCIPLES OF THERAPEUTICS 

Preparation. — Liquor Plumbi Subacetatis (Goulard's Extract). 
This preparation also contains lead oxide, and should be used 
only externally and in very dilute solutions, not more than 4 or 5 
per cent. 

Comment. — There is no internal use for lead acetate. 

PODOPHYLLUM— Mandrake— May Apple 

Podophyllum occurs as the dried rhizome and roots, and is 
used best in its preparation, Resina Podophylli, the dose of 
which is 0.01 Gm. (}£ grain). 

Comment. — Podophyllum is used as a laxative, and best 
combined with some other laxatives. Large doses cause severe 
purging. 

POTASSII BIT ARTR AS— Cream of Tartar 

Potassium bitartrate occurs as crystals or as a white powder, 
and has an acidulous taste. The average dose is 2 Gm. 
(30 grains). 

Comment. — Potassium bitartrate is somewhat diuretic. In 
large doses it is a laxative. It rather tends to increase the 
acidity of the urine, and has been often used for its diuretic 
effect in cardiac dropsy and sometimes in kidney dropsy. 
A pleasant diuretic drink may be made as follows: 

Potassium bitartrate 10 Gm. (5iiss) 

Tartaric acid 5 Gm. (gr. lxxv) 

The juice of one lemon. 

Water 1000 mils (1 quart) 

This should be sweetened to the taste, and the whole taken 
during twenty-four hours. 

POTASSII BROMIDUM 

Potassium bromide occurs as crystals or powder, has a dis- 
agreeable taste, and is very soluble in water. 

Comment. — Potassium bromide is a hypnotic which has no 
advantage over sodium bromide, and the latter is pleasanter to 
take and less of a muscle depressant. However, in epilepsy 
potassium bromide may be the better drug to use, because it 



DRUGS AND PREPARATIONS OF U. S. P. 87 

is more depressant. The average dose to produce sleep is 2 Gm. 
(30 grains), given with plenty of water, and administered three 
hours before bedtime. 

POTASSII CHLORAS 

Potassium chlorate occurs in crystals or granular powder, 
has a disagreeable saline taste, and is soluble to about 5 per 
cent, in water. 

Comment. — Potassium chlorate is a very valuable local treat- 
ment for inflammation of the mucous membrane of the mouth 
and throat. Tablets of potassium chlorate should not be 
sucked and the saturated saliva swallowed. Also there is 
absolutely no excuse for administering potassium chlorate 
internally. It is irritant, and can cause nephritis and inflam- 
mation of the liver. It may also destroy red corpuscles. As 
a gargle it may be given in 5 per cent, solution in water or in 
peppermint water. It may be combined with boric acid for 
this purpose. 

POTASSII CITRAS 

Potassium citrate occurs as crystals or powder, and is very 
soluble in water. 

Comment. — This is not an antacid in the stomach. It is a 
mild diuretic and tends to alkalize the urine, if give in sufficient 
amount. It is rapidly absorbed, and increases the alkalinity of 
the blood, and for its best action it should be given directly after 
meals. It may somewhat lower blood-pressure, and it increases 
nitrogenous metabolism as do all the alkaline salts. It may 
quiet nervous irritability. It is pleasanter to take, and has 
all the value of potassium acetate and potassium bicarbonate, 
both of which are more disagreeable drugs. There is no need 
for the historic "A B C mixture," i.e., potassium acetate, 
potassium bicarbonate, and potassium citrate. The average 
dose to alkalize the urine is 2 Gm. (30 grains) in 10 mils of 
peppermint or wintergreen water, given four times a day. 
A pleasant method of administering it is in the form of the 
official Potassii Citras Ejfervescens, the average dose of which is 
a teaspoonful dissolved in a glass of water. 



88 THE PRINCIPLES OF THERAPEUTICS 

POTASSII ET SODII TARTRAS— Rochelle Salt 

Potassium and sodium tartrate occurs mostly as a white 
powder, very soluble in water. The average dose is 10 Gm. 
(i} 2 drachms). 

Comment. — Potassium and sodium tartrate is efficient and 
less disagreeable than magnesium sulphate or sodium sulphate. 
It is pleasantly administered in the form of the official prepara- 
tion, Pulvis Efferoescens Compositus (Seidlitz Powder). This 
preparation occurs as two papers. In the blue paper is wrapped 
sodium bicarbonate and potassium and sodium tartrate. In 
the white paper is wrapped tartaric acid. The contents of the 
white paper should be dissolved in }{ of a glass of water, and 
the contents of the blue paper dissolved in }£ of another glass 
of water; they should then be poured together and the whole 
drunk slowly as it is finishing effervescing. It should not be 
taken while it is in active ebullition. 

POTASSII HYDRO XIDUM— Caustic Potash 

Potassium hydroxide occurs as dry white masses or in fused 
pencils, and is very soluble in water. 

Comment. — This preparation is very active as an escharotic, 
but it is difficult to limit its action. It may be used in 5 to 10 
per cent, solutions to remove thickened epidermis. 

POTASSII IODIDUM 

Potassium iodide occurs as crystals or powder, very soluble 
in water, and has a disagreeable, saline taste. The average 
dose is 0.30 Gm. (5 grains). 

Comment. — As the therapeutic value of an iodide, or iodine, 
is generally obtained only after long administration, it is well 
to consider the extra depressant action from the potassium salt 
as compared with the sodium salt. Therefore generally sodium 
iodide is better than potassium iodideo Also it is less dis- 
agreeable to take. 

POTASSH NITRAS— Saltpetre 

Potassium nitrate occurs as a crystalline powder. 

Comment. — There is no use for this preparation internally. 
Papers dipped in solutions of this salt are dried, then burned 



DRUGS AND PREPARATIONS OF U. S. P. 89 

and the vapor inhaled for the relief of asthma. The effect is 
that of a nitrite, namely, to relax spasm. In most combinations 
of asthmatic powders, pastilles, or cigarettes potassium nitrate 
is one of the ingredients, as it not only has its medicinal nitrite 
properties, but also causes the whole powder to burn quickly. 

POTASSII PERMANGANAS 

Potassium permanganate occurs as purplish prisms and is 
soluble in water. 

Comment. — It has no good internal use. Externally it is 
used in various strength solutions from i to 1,000 parts of 
water to 8 to 1,000 parts of water. It has been much used for 
injections into the bladder, vagina and rectum. It has also been 
used to inject into the tissues surrounding the region bitten 
by a poisonous snake, and has been used in weak solution to 
wash out the stomach in morphine poisoning. 

PRUNUS VIRGINIAN A— Wild Cherry 

Comment. — This is used only in the form of the official 
Syrupus Pruni Virginiance, which is a pleasant menstruum, 
in teaspoonful doses. It has no medicinal value. 

PYROGALLOL— Pyrogaliic Acid 

Pyrogallol occurs as white needles which are soluble in water. 

Comment. — This preparation is an irritant to the skin 
which it stains brown, and is germicidal to vegetable parasites 
that infect the skin. If used on too large a surface it may be 
absorbed in sufficient amount to cause poisoning, the symptoms 
of which are somewhat similar to those of phenol poisoning. It 
is used in the treatment of ringworm, favus, psoriasis, etc. in 
watery solution of J^ per cent., painted daily on the parts 
affected, or it may be used in a 10 per cent, ointment. It is 
sometimes used in the place of chrysarobin. 

QUASSIA— Bitter Wood 

Quassia occurs as chips or shavings from the wood. 
Comment. — Quassia is rarely used internally in the form of 
the tincture, which represents 20 per cent, of the drug. The 



go THE PRINCIPLES OF THERAPEUTICS 

dose is half a teaspoonful, in water, before meals. It is intensely 
bitter, and its only action is that of a bitter tonic. As an anthel- 
mintic, decoctions are made of the wood; 50 Gm. (about 2 
ounces) of the chips to 750 mils (i}i pints) of water is boiled 
down to 500 mils (a pint). This solution may be injected 
into the rectum (which has previously been cleansed by injec- 
tions of water) for pinworms. 

QUININA 

Comment. — Quinine is the most active alkaloid of cinchona, 

and is administered in the form of one of its salts, all of which 

are bitter. Quinines Bisulphas is very soluble in water; Quinines 

Dihydrochloridum is also very soluble in water. Quinines et 

UrecB Hydrochloridum (a compound of the hydrochlorides of 

quinine and urea) is very soluble in water and is used hypoder- 

matically in an average daily dose of 1 Gm. (15 grains). Quinines 

Hydrobromidum is not very soluble in water. Quinines 

Hydrochloridum is soluble in water. Quinines Sulphas, the most 

used salt, is practically insoluble in water, but is readily absorbed 

when taken internally. This salt should not be given except 

in pill or capsule. If a solution is desired, one of the more 

soluble salts should be selected. The average dose of any one 

of these salts as a tonic is 0.10 Gm. (1% grains), taken three 

times a day, after meals. The anti -malarial dose is much 

larger. 

RESORCINOL— Resorcin 

Resorcinol occurs in colorless crystals or as a powder, very 
soluble in water. 

Comment. — There is no excuse for using resorcinol internally. 
Externally it has a mild antiseptic action, and is of value in 
solutions in hair tonics and in soaps for shampoo purposes. 

RHEUM— Rhubarb 

Rhubarb occurs as the rhizome and roots of the plant, and 
powdered rhubarb is of a yellowish-orange color. The taste is 
bitter and astringent, as it contains tannic acid. 

Preparations. — Extr actum Rhei is a powdered extract of rhu- 
barb, and the average dose is 0.25 Gm. (4 grains). Fluidex- 



DRUGS AND PREPARATIONS OF U. S. P. 91 

tr actum Rhei, is given in the average dose of i mil (15 minims). 
Pilulce Rhei Composite, each pill containing 2 grains of rhubarb 
and 1% grains of aloes, are given in doses of one or two pills. 
Pulvis Rhei Compositus (Gregory's Powder) is a powder con- 
taining 25 per cent, of rhubarb, 65 per cent, of magnesium 
oxide, and 10 per cent, of Jamaica ginger, and the average 
dose is 2 Gm. (30 grains). Tinctura Rhei Aromatica contains 
20 per cent, of rhubarb, besides cinnamon, clove and nutmeg. 
The average dose is Jl2 a, teaspoonful. From this preparation 
is made the Syrupus Rhei Aromaticus, and this aromatic 
syrup is a pleasant purgative for children, the average dose of 
which is 2 teaspoonfuls. 

Comment. — Rhubarb is rarely used as such, but sometimes 
the root is chewed, though it is bitter and disagreeable. Owing 
to its tannic acid it is more or less of a tonic to the intestines , 
and when it is used as a purgative causes a later constipation. 
It is excreted in the milk, and hence should ordinarily not be 
taken by nursing mothers, especially as it causes the milk to 
taste bitter. 

SANTONINUM 

Santonin occurs as colorless prisms or crystalline powder, is 
insoluble in water, and the average dose is 0.06 Gm. (1 grain). 

Comment. — This preparation is used as an anthelimintic 
especially in the treatment of roundworms. It easily causes 
poisoning, and the symptoms are tremors and even convulsions, 
and sometimes disturbances of the eye sight. Consequently 
this drug should never be administered without the supervision 
and orders of a physician. The following combination is a 
good method of administration. 

Santonin 0-03 Gm. 

Calomel . . . . 0.02 Gm. 

Sugar or milk 0.30 Gm. 

Make 1 powder. 

Give such a powder every hour for three doses. One hour after 
the last dose it is well to give a saline purgative,in the proper 
dose for the age of the child, and very agreeable for this purpose 
is the Liquor Magnesii Citratis. 



02 



THE PRINCIPLES OF THERAPEUTICS 



SAPO MOLLIS 

The soft soap of the Pharmacopoeia is made from cottonseed 

oil. 

Preparation. — Linimentum Saponis Mollis. 

SCILLA— Squill 

The powder of this drug is of a yellow color and is bitter and 
acrid. The average dose is o.io Gm. (i}$ grains). 

Preparations. — Acetum Scillce (Vinegar of Squill) the average 
dose of which is i mil (15 minims); Fluidextr actum S cilice, the 
average dose of which is 0.1 mil (i^ minims). Tinctura 
ScilloB is a 10 per cent, preparation of squill, and the average 
dose is 1 mil (15 minims). 

Comment. — Squill is a stimulant diuretic and has some slight 
tonic action on the heart. Poisonous doses cause vomiting, 
irritation and congestion of the kidneys, muscle and heart de- 
pression, and finally collapse. There is no excuse for using this 
drug as an expectorant or as an emetic. It is often combined 
with digitalis in cardiac dropsy. It should be used with care 
in renal disease. 

SCOPOLAMINE HYDROBROMIDUM— Hyoscine Hydrobromide 

Scopolamine hydrobromide occurs as colorless crystals, very 
soluble in water. The average dose is 0.0003 Gm. (1/200 
grain). 

Comment. — Scopolamine hydrobromide is a hypnotic, but 
like other atropines it may cause cerebral excitement in patients 
who have an idiosyncrasy against it. This drug is mostly 
given hypodermatically. The dose above suggested should be 
the beginning dose, although twice that amount may be given^ 
if a patient is found tolerant to it. 

SENNA 

Senna occurs as dried leaflets. The average dose is 4 Gm,. 
(1 drachm). 

Preparations. — Fluidextr actum Senna, the average dose of 
which is 2 mils (30 minims) ; Puhis Glycyrrhizce Compositus 



DRUGS AND PREPARATIONS OF U. S. P. 93 

(Compound Licorice Powder) contains, besides senna, sulphur 
and glycyrrhiza. The average dose is 4 Gm,. (1 drachm). 

Comment. — Senna is a valuable, non-irritant laxative. The 
leaves may be chewed, or they may be chopped up with figs and 
taken as a laxative confection. 

SODII BENZOAS 

Comment. — Sodium benzoate is a weak antiseptic and pre- 
servative. It has no use internally. It has been used as a 
preservative for food, but its use was prohibited on account of 
its insidious irritant action on the kidneys. 

SODII BICARBONAS 

Sodium bicarbonate occurs as a white opaque powder, soluble 
in water. The average dose is 1 Gm,. (15 grains). 

SODII BORAS— Borax 

Sodium borate occurs as colorless prisms or as a white powder. 
It is soluble in water. 

Comment. — Sodium borate should not be used internally. 
Externally it is a mild soothing antiseptic to mucous mem- 
branes, and is used for the same purposes as is boric acid and in 
solutions of the same strength. 

SODII BROMIDUM 

Sodium bromide occurs as white crystals or granular powder, 
and is very soluble in water. 

Comment. — Sodium bromide is the best of the bromides to 
use for hypnotic or other purposes. The average hypnotic 
dose is 2 Gm. (30 grains). 

SODII CACODYLAS 

Sodium cacodylate occurs as white prisms or granular powder, 

and is very soluble in water. The average dose is 0.06 Gm. 

(1 grain). 

SODII CITRAS 

Sodium citrate occurs in small crystals or white granular 
powder, and is very soluble in water. 



04 THE PRINCIPLES OF THERAPEUTICS 

Comment. — This preparation may be used for the same 
purposes as is potassium citrate and in the same doses. 

SODII HYDRO XIDUM— Caustic Soda 

Sodium hydroxide occurs as white masses or fused pencils, 
and is very soluble in water. It is used as an escharotic. 

SODII IODIDUM 

Sodium iodide occurs as colorless crystals or white crystalline 
powder, is very soluble in water, and the average dose is 0.30 
Gm. (5 grains). 

Comment. — This preparation is more valuable than potas- 
sium iodide because it has the same therapeutic effect and is 
less depressant to the system than is the potassium salt. 

SODII NITRIS 

Sodium nitrite occurs as white masses or granular powder, 
is very soluble in water, and the average dose is 0.06 Gm. (1 
grain). 

Comment. — This drug is sometimes used as a vasodilator, as 
it acts longer than does nitroglycerin. It is irritant, and should 
be taken after meals, with plenty of water. 

SODII PHOSPHAS 

Sodium phosphate occurs as prisms or as a granular salt, is 
soluble in water, and •tastes like table salt. The average dose 
is 4 Gm. (1 drachm). 

Preparation. — Sodii Phosphas Exsiccatus, from which is 
prepared the official Sodii Phosphas Ejfervescens, which offers 
a very pleasant method of taking sodium phosphate, the 
average dose of which is 10 Gm. (2^ drachms). 

Comment. — Sodium phosphate is a gentle laxative and 
seems to especially relieve congestion of the liver. 

SODII SALICYLAS 

Sodium salicylate occurs as a white crystalline or amorphous 
powder, and is very soluble in water. The average dose is 
1 Gm. (15 grains). 



DRUGS AND PREPARATIONS OF U. S. P. 95 

Comment. — Sodium salicylate is one of the most useful 
preparations of salicylic acid. 

SODII SULPHAS— Glauber's Salt 

Sodium sulphate occurs as large prisms or granular crystals, 
is very soluble in water, and has a bitter, saline, very dis- 
agreeable taste. The average dose is 15 Gm. (4 drachms). 

SPARTEINE SULPHAS 

Sparteine sulphate is prepared from sparteine, a liquid 
alkaloid obtained from scoparius, and occurs as a crystalline 
powder, very soluble in water. The average dose is 0.01 Gm. 
(% grain). 

Comment. — This preparation has been used as a diuretic and 
as a heart stimulant in certain conditions. In too large doses 
it acts as a nervous and circulatory depressant. It is not a 
very useful drug. 

SPIGELIA— Pinkroot 

Preparation. — Fluidextr actum Spigelia. The average dose 
is 1 teaspoonful. 

Comment. — Pinkroot is used as an anthelmintic in the 
treatment of roundworms. It is best given in the form of the 
fluidextract combined with fluidextract of senna in equal parts, 
a teaspoonful of the combined drugs being given, in water, 
every two hours for three doses, to be subsequently repeated, 
if needed. 

ST APHIS AGRI A— S tavesacre 

Comment. — Staphisagria should be used externally only. 
It is used as a wash or ointment to destroy lice. 

STRAMONIUM— Jamestown Weed 

Comment. — There is no need for this drug or its preparations 
as its action is similar to that of belladonna, and atropine 
represents the action of both stramonium and belladonna. 
However, the leaves of stramonium are sometimes burned and 
the vapor inhaled for asthma. The action is doubtless an 
atropine action. 



96 THE PRINCIPLES OF THERAPEUTICS 

STROPHANTHUS 

Comment. — Strophanthus is used only in the form of its 
tincture, Tinctura Strophanti, which represents 10 per cent, 
of the drug. The average dose should ordinarily not be more 
than 0.30 mil (5 nrinims), as it is often irritant to the gastro- 
intestinal tract. This tincture should generally be ordered 
alone, as it does not well combine, and also it quickly deterior- 
ates. Digitalis action should not be expected from tincture of 
strophanthus when administered by the mouth. 

The active principle of strophanthus, Strophanthinum (stro- 
phanthine which is a mixture of glucosides obtained from 
strophanthus, is used hypodermatically or intravenously as a 
very strong cardiac tonic. The intravenous dose is about 
Koo of a grain. 

STRYCHNIN A 

Comment. — Strychnine is rarely used except in the form of 
one of its salts, Strychnin® Nitras or Strychnina Sulphas. 
These occur as crystalline powders, which are soluble in con- 
siderable water. The average dose is 0.0015 Gm. (3^0 grain). 

SULPHONETHYLMETHANUM— Trional 

Sulphonethylmethane occurs as colorless crystals, has a 
bitter taste, and is practically insoluble in water. The average 
dose is 0.75 Gm. (12 grains). 

Comment. — Trional is a hypnotic that is slow to act, and 
has been largely superseded by veronal. 

SULPHONMETHANUM— Sal phonal 

Sulphonmethane is a crystalline powder, is practically in- 
soluble in water, and the average dose is 0.75 Gm. (12 grains) 

Comment. — This hypnotic acts very slowly, and has been 
superseded more or less by veronal. 

SULPHUR LOTUM. Washed Sulphur 

Washed sulphur occurs as a fine yellow powder without odor 
or taste, is insoluble in water, and the average dose is 4 Gm. (1 
drachm) . 



DRUGS AND PREPARATIONS OF U. S. P. 97 

Comment. — Washed sulphur is the best preparation for in- 
ternal use. It may be used for laxative purposes, or as a so- 
called bowel antiseptic. Sometimes sulphur is given internally 
for its supposed effect on boils or on eruptions of the skin. The 
stools caused by sulphur are soft but not watery, and give off 
a strong odor of hydrogen sulphide. At the same time the 
breath and the perspiration smell of hydrogen sulphide, and 
this gas is also excreted in the milk. 

SULPHUR PR^CIPITATUM— Milk of Sulphur 

Precipitated sulphur occurs as an amorphous powder, has a 
pale yellow color, is without odor or taste, and is insoluble in 
water. The average dose is 4 Gm. (1 drachm). 

Comment. — If it is desired to give a sulphur preparation in- 
ternally, as the dose is large and disagreeable to take, it may be 
administered in a syrup or in a soft jam or. thin cereal. 

SULPHUR SUBLIMATUM— Flowers of Sulphur 

Sublimed sulphur occurs as a fine yellow powder, has a 
characteristic ordor, and is insoluble in water. 

Preparation. — Unguentum Sulphuris is a 15 per cent, ointment 
of sulphur, which is often too strong for most skins. It is used 
principally in scabies. 

Comment. — The flowers of sulphur may be used as a powder 
externally for scabies. 

SUPRARENALUM SICCUM— Desiccated Suprarenal Glands 

This preparation is made from the suprarenal glands of ani- 
mals used for food, and should contain fron 0.4 to 0.6 per cent, 
of epinephrine. It occurs as a yellowish-brown powder. 

TALCUM PURIFICATUM 

Purified talc occurs as a fine grayish-white powder, and is 
used as a dusting powder and in tooth pastes. 

TERPINI HYDRAS 
Terpin hydrate occurs as colorless prisms which are practically 

insoluble in water. 
7 



gS THE PRINCIPLES OF THERAPEUTICS 

Comment. — This preparation is used to inhibit secretion of 
the air passages. Solutions in alcohol are unsatisfactory, be- 
cause the dose represented is not of sufficient size. It is best 
administered in powder, capsules, or tablets, the tablet to be 
crushed before swallowing and taken with plenty of water, 
although it is non-irritant. The average dose is 0.30 Gm. (5 
grains) and should be taken four times a day. 

THEOBROMINE SODIO-SALICYLAS— Diuretin 

Theobromine sodio-salicylate occurs as a white powder, and 
is very soluble in water. 

Comment. — This preparation x first offered under the name of 
diuretin, is a much over-lauded diuretic drug. It is not irritant, 
is a slight cardiac stimulant, and slightly stimulant to the kidney 
epithelium. It is contraindicated whenever caffeine is con- 
traindicated. It may be used in cardiac dropsy. It is not 
pleasant tasted, and is best given in 0.50 Gm. (7^ grains) cap- 
sules, which should be uncapped before swallowing and taken 
with plenty of water. Larger doses are often administered. 

THYMOL 

Thymol is a phenol, and occurs as colorless prisms, has an 
aromatic odor and a pungent taste, is practically insoluble in 
water, but very soluble in alcohol. 

Comment. — This drug is somewhat antiseptic, and for this 
purpose it is added to gargles and sprays, in weak solutions. 
It should not be used internally for any purpose except as an 
anthelmintic in the treatment of hookworm, as it is likely to 
cause poisoning. The method of administration and the dose 
for that purpose will be found under the detailed treatment of 
that disease. 

THYMOLIS IODIDUM— Aristol 

Thymol iodide occurs as a reddish-brown powder, has a 
characteristic aromatic odor, and is insoluble in water. 

Comment. — Aristol is used as a drying, mildly antiseptic 
dressing for wounds and ulcers. 



DRUGS AND PREPARATIONS OF U. S. P. 99 

THYROIDEUM SICCUM— Dried Thyroids 

This preparation is made from the thyroid glands of animals 
used for food, and should contain from 0.17 to 0.23 per cent, of 
iodine. It occurs as a yellowish, amorphous powder. 

Comment— Dried thyroid is a very potent substance. The 

dose should be entirely regulated by the condition for which it 

is used. An average dose is 0.06 Gm. (1 grain). This drug 

should not be sold by druggists except on the prescription of a 

physician. 

TRINITROPHENOL— Picric Acid 

Trinitrophenol occurs as pale yellow scales, is not very solu- 
ble in water, but more soluble in alcohol. 

Comment. — Picric acid is used externally for burns. It has 
no internal use. 

VERATRUM VIRIDE— Green Hellebore— American Hellebore 

Veratrum viride is the dried rhizome and roots of the plant. 

Preparations. — Fluidextr actum Veratri Viridis, the average 
dose of which is 0.1 mil (ij^ minims); Tinctura Veratri Viridis 
represents 10 per cent, of the drug, and the average dose is 0.50 
m il (7M minims). 

ZINCI CARBONAS PRiECIPITATUS 

Precipitated zinc carbonate occurs as a white, impalpable 
powder. 

Comment. — This preparation is used as a drying and dusting 
powder. The impure zinc carbonate is termed calamine. 

ZINCI OXIDUM 

Zinc oxide occurs as a fine white or yellowish-white powder. 
Preparation. — Unguentum Zinci Oxidi. 

Comment. — This preparation is slightly astringent, and is 
used as a protective powder. 

ZINCI STEARAS 

Zinc stearate occurs as a fine white powder. It has a greasy 
feel, is adherent to the skin, and therefore is used as a protective 
powder. 



IOO THE PRINCIPLES OF THERAPEUTICS 

ZINCI SULPHAS 

Zinc sulphate occurs as crystals or a crystalline powder, is 
very soluble in water, and is strongly astringent. 

Comment. — This preparation has no use internally except as 
an emetic. The dose for that purpose is 2 Gm. (30 grains), 
given in solution at once and not repeated. Externally it has 
been used as an astringent, especially for injections in gonorrhea. 
Silver salts are now more frequently used for this purpose. 
The strength of solutions used is from ^ to 2 per cent. 



SYNONYMS 



The following alphabetical list of more or less used synonyms 
will be found of value for quick reference. 



Acetannin — Tannigen 

Adrenalin — Suprarenalin; Epinephrine 

Albu tannin — Tannalbin 

Alcresta Ipecac — Emetinized Fuller's 

Earth 
Antifebrin — Acetanilid 
Aqua Fortis — Nitric Acid 
Aqua Regia — Nitrohydrochloric Acid 
Aristol — Thymol Iodide 
Arsenous Acid — Arsenic Trioxide 
Atophan — Phenylcinchoninic Acid 



B 



B arbital — Veronal 

Barbital - Sodium — Sodium Diethyl- 
Barbiturate 

Basham's Mixture — Liquor Ferri et 
Ammonii Acetatis 

Basilicon Ointment — Rosin Cerate 

Benne Oil— Oil of Sesame 

Benzocaine — Anesthesine 

Bichloride — Mercuric Chloride 

Bitter Wood — Quassia 

Black Draught — Compound Infusion 
of Senna 

Black Wash— Lotio Nigra, N. F. 

Blaud Pill— Pill of Ferrous Carbonate 

Bleaching Powder — Calx Chlorinata 

Blue Mass — Massa Hydrargyri 

Blue Ointment — CJnguentum Hydrar- 
gyri Dilutum 

Blue Pill — Massa Hydrargyri 

Blue Stone — Copper Sulphate 

Blue Vitriol — Copper Sulphate 

Boracic Acid — Boric Acid 

Borax — Sodium Borate 

Boroglycerin — Glycerite of Boroglyc- 
erin 



Brown Mixture — Compound Mixture 
of Glycyrrhiza. 



Cacao Butter — Oleum Theobromatis "} 
Calamine — Zinc Carbonate 
Calcined Magnesia — Magnesium Ox- 
ide 
Calcium Oxide — Calx 
Calisaya Bark — Cinchona 
Calomel — Hydrargyri Chloridum Mite 
Camphorated Oil — Linimentum Cam- 

phorae 
Carbolic Acid — Phenol 
Carron Oil — Li nim entum Calcis 
Cassia Oil — Oil of Cinnamon 
Castor Oil — Oleum Ricini 
Caustic Potash — Potassium Hydroxide 
Caustic Soda — Sodium Hydroxide 
Cayenne Pepper — Capsicum 
Chloride of Lime — Calx Chlorinata 
Chlorinated Lime — Calx Chlorinata 
Chromic Acid — Chromium Trioxide 
Cinchophen — Phenylcinchoninic Acid ' 
Cod Liver Oil — Oleum Morrhuas 
Compound Licorice Powder — Purvis 

Glycyrrhizae Compositus 
Corrosive Sublimate — Mercuric Chlor- 
ide 
Cotton Seed — Gossypii Semen 
Cream of Tartar — Potassium Bitar- 

trate 
Croton Oil— Oleum Tiglii 



Deadly Nightshade — Belladonna 
Dermatol — Bismuth Subgallate 
Digitan — Digipuratum 
Dionin — Aethylmorphinae Hydrochlor-" 
idum 



IOI 



io: 



THE PRINCIPLES OF THERAPEUTICS 



Diuretin — Theobromine Sodio-Salicy- 
late 

DobelTs Solution — Liquor Sodii Bor- 
ates Compositus, N.F. 

Donovan's Solution — Liquor Arseni et 
Hydrargyri Iodidi 

Dover's Powder — Pulvis Ipecacuanhae 
et Opii 

E 

"Elixir Pro"— Tincture of Aloes and 
Myrrh. 

Epinephrine — Suprarenalin 
Epsom Salt — Magnesium Sulphate 
Ergot of Rye — Ergot 
Ergotine — Extract of Ergot 
Eserine — Physo'stigmine 
Eucaine — Betaeucaine 
Eucatropine — Euphthalmine 



Hive Syrup — Syrupus Scillae Composi- 
tus 
Hoffmann's Anodyne — Spirit of Ether 
Hoffmann's Drops — Spirit of Ether 
Huxham's Tincture — Compound Tinc- 
ture of Cinchona 
Hyoscine — Scopolamine 



Jaborandi — Pilocarpus 

James' Powder — Pulvis Antimonialis 

Jamestown Weed — Stramonium 



Kaolin — Aluminum Silicate 
Kentish's Ointment — Liniment um 
Terebinthinas 



Flaxseed — Linum 

Flowers of Sulphur— Sulphur Sublima- 

tum 
Fowler's Solution— Liquor Potassii 

Arseni tis 
Foxglove — Digitalis 
Fuller's Earth — Magnesium Silicate 



Gallotannic Acid — Tannic Acid 
Glauber's Salt — Sodium Sulphate 
Glusidum — Benzosulphinidum; Sac- 
charin 
Goulard's Extract — Liquor Plumbi 

Subacetatis 
Gray Powder — Hydrargyrum cum 

Creta 
Green Helebore — Veratrum Viride 
Gregory's Powder — Pulvis Rhei Com- 
positus 
Griffith's Mixture — Mistura Ferri 

Composita 
Gum Benjamin — Benzoin 

H 

Hashish — Cannabis Indica 
Heroin — D i a c e t y 1 morphine Hydro- 
chloride 



Labarraque's Solution — Liquor Sodae 
Chlorinatae 

Lanolin — Adeps Lanae Hydrosus 

Laudanum — Tincture of Opium 

Licorice — Glycyrrhiza 

Light Magnesia — Magnesium Oxide 

Lime — Calx 

Lime Water — Liquor Calcis 

Linseed — Linum 

Lugol's Solution — Liquor lodi Com- 
positus 

Luminal — Phenylbarbital 

Lunar Caustic — Silver Nitrate 



M 



Magendie's Solution — Liquor Mor- 
phinae Hypodermicus, N.F. 

Magnesia — Magnesium Oxide 

Male Fern — Aspidium 

Mandrake — Podophyllum 

May Apple — Podophyllum 

Medinal — Veronal Sodium 

Methylene Blue — Methylthionine 
Chloride 

Milk of Sulphur — Sulphur Praecipita- 
tum 

Mineral Oil — Petrolatum Liquidum 



DRUGS AND PREPARATIONS OF U. S. P. 



IO3 



Monkshood — Aconite 

Monsel's Solution — Liquor Ferri Sub- 

sulphatis 
Muriatic Acid — Hydrochloric Acid 

N 

Naphthol — Betanaphthol 
Novocaine — Betaeucaine 



Oil of Betul— Methyl Salicylate 
Oil of Cade — Oleum Cadini 
Oil of Sweet Birch— Methyl Salicylate 
Oil of Wintergreen — Methyl Salicylate 
Orphol — Bismuth Betanaphthol 



Paraform — Paraformaldehyde 

Paregoric — Tinctura Opii Camphorata 

Phenacaine — Holocaine 

Phenacetin — Acetphenetidinum 

Phenazone — Antipyrine 

Picric Acid — Trinitrophenol 

Pine Needle Oil — Oleum Pini Pumili- 

onis 
Pinkroot — Spigelia 
Plummer's Pills — Pilulae Antimonii 

Compositae 
Pomegranate — Granatum 
Precipitated Chalk — Calcii Carbonas 

Praecipitatus 
Prepared Chalk — Creta Praeparata 
Procaine — Novocaine 
Pyrogallic Acid — Pyrogallol 



Quebracho — Aspidosperma 
Quevenne's Iron — Ferrum Reductum 
Quick Lime — Calx 



R 



Red Precipitate — Hydrargyri Oxidum 

Rubrum 
Resorcin — Resorcinol 
Rochelle Salt— Potassii et Sodii Tar- 

tras 



Saccharin — Benzosulphinidum 
Salol — Phenyl Salicylate 
Saltpetre — Potassium Nitrate 
Salvarsan — Arsphenamine 
Sandalwood Oil — Oleum Santali 
Seidlitz Powder — Pulvis Effervescens 

Compositus 
Soap Liniment — Linimentum Saponis 
Spanish Flies — Cantharis 
Spirit of Turpentine — Oleum Terebin- 

thinae 
Squill — Scilla 
Stavesacre — Staphisagria 
Stypticin — Cotarnine Hydrochloride 
Sugar of Lead — Plumbi Acetas 
Sulphonal — Sulphonmethane 
Sulphurated Lime — Calcii Sulphidum 

Crudum 
Suprarenin — Suprarenalin 
Sweet Oil— Olive Oil 



Tannin — Tannic Acid 

Tartar Emetic — Antimonii et Potassii 

Tartras 
Teel Oil — Oleum Sesami 
Theine — Like Caffeine 
Trional — Sulphonethylmethane 
Tully's Powder — Pulvis Morphinae 

Compositus, U. S. P., 1900. 



U 



Urethane — Aethylis Carbamas 
Urotropin — Hexamethylenamine 



Vallet's Mass — Massa Ferri Carbon- 

atis 
Veronal — B arbital 
Veronal-Sodium — Barbital-Sodium 



W 



Warburg's Pills — Pilulae Antiperiodicae, 
N.F. 



104 



THE PRINCIPLES OF THERAPEUTICS 



Warburg's Tincture — Tinctura Anti- 
periodica, N.F. 

White Arsenic — Arseni Trioxidum 

White Precipitate — Hydrargyrum Am- 
monia turn 

Wild Cherry — Prunus Virginiana 

Witch Hazel — Hamamelis 



Wood Charcoal — Carbo Ligni 
Wormseed — Chenopodium 



Yellow Peruvian Bark — Cinchona 
Yellow Wash— Lotio Flava, N.F. 



PART in. 
THERAPEUTIC CLASSIFICATION OF DRUGS 

This classification is based on the use of drugs to meet thera- 
peutic indications. The order of the classes is arranged on the 
plan of progression from the class that lists the drugs used for 
external action to the class that lists drugs used for action on 
the most vital parts of the body. Under each class the drugs 
are named in alphabetical order, as an order of preference is 
impossible, one drug being more therapeutically efficient in one 
condition and another drug more therapeutically efficient in 
another condition. Later under each class is discussed the 
whole subject for which the class stands and briefly the action 
and use of the most important drugs. The drugs later de- 
scribed in detail appear in italics in this classification. 

FIRST DIVISION 
For Local Use 

Class I. — Drugs Used to Destroy Microorganisms. 

(a) To disinfect. — For buildings; formaldehyde; steam; sul- 
phur fumes. For clothing: formaldehyde; heat. For dejecta: 
bichloride of mercury solutions; chlorinated lime solutions; 
formaldehyde solutions; heat. 

(b) To inhibit the growth of bacteria upon the body (anti- 
septics, germicides). — Bichloride of mercury solutions; boric 
acid solutions; chlorine solutions; cresol solutions; formaldehyde 
solutions; hydrogen dioxide solutions; potassium permanganate 
solutions; phenol solutions; salicylic acid preparations. 

(c) To destroy skin parasites (parasiticides). — Balsam of 
Peru; betanaphthol; chrysarobin preparations; ichthyol; iodine 
preparations; mercury preparations; pyrogallol preparations; 
resorcin; sulphur preparations; any of the drugs named under 
"b" of this class. 

105 



106 THE PRINCIPLES OF THERAPEUTICS 

Class II. — Drugs Used Externally for Action on the 
Skin. 

(a) To allay irritation. — Bland oils (almond oil, cocoa 
butter, olive oil, petroleum oils, wool fat); borogly cerin ; gly- 
cerin; dry powders (bismuth preparations, boric acid, lyco- 
podium, starch, talcum, zinc oxide, zinc stearate). 

(b) To cause hyperemia (counterirritation) . — Alcohol; 
ammonia; capsicum preparations; tincture of iodine; liniments; 
mustard preparations; turpentine; volatile oils (especially oil 
of wintergreen (natural or artificial, methyl salicylate), oil of 
peppermint, etc.). 

(c) To blister. — Cantharides preparations. 

(d) To destroy tissue (escharotics) . — Carbon dioxide snow; 
chromium trioxide; glacial acetic acid; nitric acid; potassium 
hydroxide; salicylic acid; silver nitrate; trichloracetic acid. 

Class III. — Drugs Used for Action on Mucous Membranes. 

(a) To allay irritation. — Barley water; egg albumin; flax- 
seed infusion; milk; starch water; slippery elm infusion; sodium 
chloride (.9 per cent.) solution. 

(b) To inhibit secretion (astringents). — Bismuth salts; 
silver (weak) solutions; tannic acid. 

(c) To stimulate. — Copper salts; silver salts; zinc salts. 
Class IV. — Drugs Used for Local Action in the Stomach. 

(a) To increase the appetite. — Cinchona, gentian, and nux 
vomica, liquid preparations. 

(b) To aid digestion. — Diastase; hydrochloric acid (dilute); 
pancreatin (under certain conditions) ; pepsin. 

(c) To reduce acidity (antacids). — Ammonia preparations; 
chalk; lime water; magnesia preparations; sodium bicarbonate. 

(d) To relieve irritation. — Bismuth preparations; milk of 
magnesia; demulcents. 

(e) To cause vomiting (emetics). — Apomorphine (acting on 
the vomiting center); copper sulphate; ipecac; mustard; zinc 
sulphate. 

Class V. — Drugs Used for Local Action in the Intestinal 
Canal. 

(a) To increase peristalsis (carminatives). — Asafetida; cap- 
sicum; ginger; peppermint; all spices. 



THERAPEUTIC CLASSIFICATION OF DRUGS 107 

(b) To cause evacuation of the bowels (cathartics). — These 
may be well sub-classed as: 

Laxatives; agar: aloes (aloin); cascara sagrada; fel bovis; 
licorice (compound powder); magnesia; petroleum oil; podo- 
phyllum; rhubarb; phenolphthalein; senna; sulphur. 

Purgatives: calomel; castor oil; large doses of any laxative. 

Saline purgatives; magnesium citrate; magnesium sulphate; 
potassium and sodium tartrate; Seidlitz powder (compound 
effervescing powder); sodium phosphate; sodium sulphate. 

Irritant purgatives: colocynth; croton oil; elaterium; jalap 

(c) To diminish intestinal putrefaction. — Betanaphthol; lac- 
tic acid bacilli (Bulgarian bacilli) ; salol; sugar of milk; yeast. 

{d) To remove parasites (anthelmintics). — Aspidium; be- 
tanaphthol; emetine; pelletierine tannate; pumpkin seed ; quassia ; 
santonin; spigelia; thymol; wormseed oil. 

SECOND DIVISION 

For Systemic Action 

Class i. — Drugs Administered Internally for Their Action on 
the Skin. 

(a) To stimulate the activity of the skin. — Arsenic; 
thyroid. 

(b) To increase perspiration (diaphoretics). — Alcohol; anti- 
pyrine; pilocarpine. 

(c) To decrease perspiration. — Atropine. 

Class II. — Drugs Used for Their Action on the Genitouri- 
nary System. 

(a) To increase the amount of urine. — Buchu; caffeine; digi- 
talis; scoparius; squill; theobromine sodio-salicylate. 

(b) To render the urine alkaline. — Potassium citrate; sodium 
bicarbonate; sodium citrate. 

(c) To render the urine acid. — Hydrochloric (dilute) acid; 
acid sodium phosphate. 

(d) To prevent the growth of bacteria in the kidneys and 
bladder. — Hexamethylenamine; methylene blue; salol. 

(e) To stimulate the mucous membranes. — Oil of santal. 

(f) To increase menstruation (emmenagogues) . — Corpus 



IOS THE PRINCIPLES OF THERAPEUTICS 

luteum; iron, manganese dioxide (precipitated); ovarian ex- 
tract, thyroid extract. 

(g) To contract the uterus (oxytocics). — Ergot; hydrastinine; 
mammary extract; quinine; pituitary extract. 

Class III. — Drugs Used for Action on the Respiratory 
Tract. 

(a) To increase the secretion of the mucous membranes 
(expectorants). — Ammonium chloride (small doses); ipecac; 
iodides. 

(b) To decrease the secretion of mucous membranes. — 
Ammonium chloride (large doses) ; atropine; codeine; morphine; 
terpin hydrate; various balsam and aromatic oil inhalants. 

(c) To relax spasm. — Atropine; bromides; chloral; morphine; 
nitroglycerin; stramonium; suprarenal preparations (in some 
conditions) . 

Class IV. — Drugs Used for Action on the Circulation. 

(a) To accelerate the heart. — Atropine; camphor; caffeine; 
strychnine. 

(b) To depress the heart. — Aconite; coal-tar drugs veratrum 
viride. 

(c) To strengthen the heart. — Caffeine; digitalis; strop han- 
thin; strychnine; pituitary extracts. 

(d) To contract the blood-vessels (vaso-constrictors) . — 
Atropine; caffeine; ergot; pituitary extracts; suprarenal 
extracts. 

(e) To dilate the blood-vessels (vaso-dilators) . — Alcohol; 
nitrites. 

Class V. — Drugs Used for Action on the Central Nervous 
System. 

(a) To stimulate the brain and spinal cord. — Atropine; 
caffeine; camphor; strychnine; thyroid. 

(b) To depress the brain and spinal cord. — Acetanilid; anti- 
pyrine; aspirin; bromides; chloral; gelsemium; opium and its 
alkaloids; phenacetin. 

(c) To stop acute pain (analgesics). — Opium and its alkaloids; 
chloroform; ether. 

(d) To cause sleep (hypnotics). — Bromides; chloral; paralde- 
hyde; scopolamine; sulphonal; veronal (barbital). 



THERAPEUTIC CLASSIFICATION OF DRUGS 109 

0) To cause general anesthesia. — Chloroform; ether; nitrous 
oxide gas. 

(f) To cause local anesthesia. — Cocaine; ethyl chloride; ice; 
menthol; phenol; procaine (novocaine). 

Class VI.— Drugs Used to Lower the Temperature of the Body 
(antipyretics). — Acetanilid; antipyrine; cold; phenacetin. 
Class VII. — Drugs and Preparations that are Specific. 

Antidiphtheritic serum in diphtheria. 

Antitetanic serum in tetanus. 

Antimeningococcic serum in meningococcic meningitis. 

Arsphenamine and mercury in syphilis. 

Calcium in tetany. 

Oranges and lemons in scurvy. 

Quinine in malarial fevers. 

Serum in bleeding. 

Thyroid extract in cretinism and myxedema. 
Class VIII. — Drugs Used as Specifics. 

Colchicum in acute gout. 

Salicylic acid in acute rheumatism. 
Class IX. — Drugs Used to Modify Metabolism. 

Arsenic to stimulate metabolism. 

Alkalies to combat hyperacidity. 

Calcium to promote bone nutrition. 

Iodides to modify sclerosis. 

Iron to combat anemia. 

Phenylcinchoninic acid (cinchophen, atophan) to increase 
the excretion of uric acid. 

ACTION AND USES OF VALUABLE DRUGS 

Under this section only the most important drugs are briefly 
described. All other drugs named in the classification and 
many not named will be found tersely mentioned and com- 
mented upon in Part II, the section on the United States Phar- 
macopceial drugs and preparations. 

In describing the important drugs in this section it is aimed to 
give briefly the positive activity of each useful drug; to describe 
its over-action; to suggest the treatment of poisoning from it; to 
recommend its use in certain conditions; and to state how it is 



HO THE PRINCIPLES OP THERAPEUTICS 

best administered. Detailed pharmacology of, and long essays 
on, these drugs and on those not here described may be found 
in all good textbooks on materia medica and pharmacology. 

FIRST DIVISION 

CLASS I 

Drugs Used to Destroy Microorganisms 

disinfection 

The relation to each other of the terms "disinfectants" and 
" antiseptics " has been much discussed. A disinfectant to be 
such must be able to kill germs, i.e., be a germicide. An 
antiseptic may prevent germs from growing, and still not be a 
germicide. 

Fumigation is terminal disinfection, i.e., disinfection of 
buildings, rooms, household furnishings, beds, and clothing. 
Fumigation to be efficient must kill all live creatures, including 
rats, mice, flies, mosquitoes, fleas, lice, bed-bugs, and bacteria. 

The value of and the method of using a given disinfectant 
depend on the object for which it is to be used. In other words, 
it is obvious that an efficient disinfectant for a room or for 
clothing may not be a suitable disinfectant for the hands or for 
excreta. 

If disinfective measures are properly carried out at the bed- 
side of a patient who has a contagious disease, infection of others 
will rarely occur, and the necessity for terminal disinfection be- 
comes more or less unnecessary, depending, of course, upon the 
disease. 

The first object of a physician who is called to care for a con- 
tagious disease is to circumscribe the contagium. Toward this 
end he sends the patient to a contagious disease hospital, if pos- 
sible. If this is not feasible, or the disease does not require that 
sort of isolation, he selects for the patient the most suitable room 
in the house, or tenement, one that is light, airy, remote, and 
as closely associated with a bathroom as possible. He removes 
unnecessary furniture and furnishings, and selects a trained 
nurse, or instructs the mother or some other member of the 
family, as to the care for the patient. He then endeavors to 



DISINFECTION III 

confine the germs of contagion to the sick-room by hanging at 
the door a sheet, wet with a chlorinated lime or a phenol solution. 

Present knowledge shows that most contagion is direct,even 
the contagium of small-pox not being able to travel more than a 
few feet. However, "direct contagion" can occur at any dis- 
tance, when clothing or other articles have become infected 
by contact with the secretions of the patient, and such con- 
tagium being swallowed, inhaled, or otherwise absorbed by an 
individual who is not immune may cause infection. It has 
been proved that most contagiums are transmitted by "car- 
riers," who may harbor disease with immunity and impunity, 
and by "missed" cases, patients who have the disease but who 
are so slightly sick that their illness is not recognized. Also 
many diseases are acquired only by infection from an inter- 
mediate host, such as lice, fleas, mosquitoes, etc. 

Some pathologic bacteria die very quickly when exposed to 
the air, and especially when exposed to the sun. The patho- 
genic bacteria that seem to be the shortest lived are the germs of 
influenza, cerebrospinal fever, gonorrhea, and probably the 
germ of anterior poliomyelitis. The contagium of whooping 
cough survives during a short period only, though the disease 
still progresses. Diphtheria bacilli, typhoid bacilli, and tubercle 
bacilli may survive in dust or other material for a considerable 
length of time; however, diphtheria and tuberculosis are prob- 
ably rarely thus acquired, but generally by the more direct 
"droplet" method of transmission. 

The germs of typhoid and paratyphoid fevers, of dysentery, 
of cholera, and perhaps other germs that cause diarrhea, are 
not air -borne, but are acquired by the contamination of some 
food or liquid that is taken into the stomach unsterilized. 
Typhus fever has been shown to be caused by the bites of in- 
fected lice, and bubonic plague by the bites of infected fleas. 

Because ordinary colds, tonsillitis and influenza so rapidly 
spread, it was thought they were disseminated by the air, but 
it is now known that they are only spread by contact, although 
the air near the patient may become contaminated by coughing, 
sneezing, laughing, and even by loud talking, unless a handker- 
chief or other protection is used. Some inflammations of the 



112 THE PRINCIPLES OF THERAPEUTICS 

eye, and some contagious diseases of the skin are spread only by 
contact. Measles and scarlet fever are spread by secretions 
from the upper air passages, or perhaps from a suppurating ear, 
but not by the eruptions on the skin. Pneumonia also is acquired 
by close contact with the secretions of those who are ill with 
pneumonia or are carriers of pneumonia germs. 

One of the aids to direct contact is the fly, which can carry 
in its mouth and on its feet the germs of contagion and deposit 
them on food or liquid, or on handkerchiefs, or in some way 
that direct contact may be caused, or it may deposit germs on 
the lips or face of the individual. In other words, the fly is a 
menace, especially where there is contagion; therefore the sick- 
room must be screened absolutely against flies. 

Infected mosquitoes are the cause of malarial fever and of 
yellow fever. Certain types only of mosquitoes become in- 
fected by biting individuals who have these diesases, but after 
such infection they are ready to transmit it by their bites to 
individuals of the human race. Hence patients with malarial 
fever or with yellow fever must be screened against the possi- 
bility of mosquitoes becoming infected and thus transmitting 
the disease to others. 

As just stated, terminal disinfection is now rarely necessary 
although fumigation may still be done in certain conditions. 
Fumigation of schoolrooms, however, and of school buildings, 
is an unnecessary expense. Spraying the floor and washing the 
region in which a child has been, when he developed an infec- 
tious disease, with antiseptics such as corrosive sublimate solu- 
tions and strong formaldehyde solutions, is the proper course 
to pursue. Books, pencils, etc. should generally be destroyed. 
If a book is valuable, it may be subjected to dry heat or placed 
in a formaldehyde cabinet. 

With the object that the infecting agent must be confined to 
the patient's room and not be allowed to get out of it, and with 
the knowledge that the contagium is carried by some of the ex- 
cretions or secretions of the body, the instructions of the phy- 
sician to the nurse are for her to so dress that she cannot readily 
carry the germs; for her to properly cleanse her hands before 
eating or drinking; and for her to be sure that the patient's eat- 



DISINFECTION 



"3 



ing utensils are placed in boiling water or otherwise thoroughly 
cleansed before they are allowed to be taken to other parts 
of the house. All secretions of the nose and throat and all spu- 
tum from coughing should be received on gauze or paper napkins, 
which should be immediately deposited in a paper bag, and the 
bag and contents be later burned. If the disease is one which 
is transmitted by coughing and spraying, when the nurse is near 
the patient she should wear a rather thick mask protection for 
the nose and mouth. 

For the disinfection of the hands of the nurse, or others in 
attendance, a 1-1,000 solution of bichloride of mercury, or a 2.5 
per cent, solution of phenol, or a 1.5 per cent, solution of chlori- 
nated lime are efficient. When advisable, especially while the 
nurse is caring for the stools in cholera, dysentery, typhoid 
fever, and paratyphoid fever, it is well for her to wear 
rubber gloves, which she can cleanse and keep in sterile 
solutions. 

The patient's urine should be passed into a receptacle con- 
taining a 5 per cent, chlorinated lime solution, or a 1-500 
mercuric chloride solution. The urine should then be allowed 
to stand, covered, in this vessel for an hour or more before it 
is poured down the closet. The feces should be passed into the 
same solutions, but an equal quantity of a 25 per cent, chlori- 
nated lime mixture should be added after the fecal matters have 
been broken up. The receptacle should then be covered and 
allowed to stand two hours or more before the contents are 
poured down the closet. The patient's buttocks may be 
cleansed with gauze wet with a 1-1,000 bichloride of mercury 
solution or a 2.5 per cent, phenol solution, unless the parts are 
irritated and sore. In this case, saturated solutions of boric 
acid may be used. 

The strength of other solutions used to disinfect the excreta 
are: 5 per cent, phenol solutions; 3 per cent, cresol solutions; 
5 per cent, copper sulphate solutions; and 5 per cent, solutions of 
the official Liquor Formaldehydi. 

The clothing of the patient and the bed clothing should be 
placed in a 5 per cent, formaldehyde solution or in a 1-2,000 
bichloride of mercury solution, and should remain in the 



114 THE PRINCIPLES OF THERAPEUTICS 

solution some hours before they are sent to the laundry, where 
they can be subsequently boiled. 

With the understanding that the skin does not carry infec- 
tion in the majority of contagious diseases, although it may be 
contaminated at some part by some secretion which carries 
infection being deposited upon it, general antiseptic baths are 
usually inadvisable until possibly just before the patient is to 
leave the contagious ward or the sick-room. At that time he 
may be bathed in a weak (i- 10,000) solution of bichloride of 
mercury, if it seems advisable, afterwards bathed with boric 
acid solutions, and wrapped in an absolutely clean sheet before 
he goes into another room and puts on clean clothing. His 
hair should have been properly shampooed and cleansed before 
his bath. It should be remembered that the long tedious 
desquamation of scarlet fever does not carry the contagium of 
that disease. 

The blankets, comfortables, and many equipments of the 
room, rugs, etc., may be steamed or dry heated to sterilization; 
or the whole room may be fumigated with formaldehyde or with 
sulphur. All doors, windows and other openings of the room 
must be sealed before fumigation. Five pounds of sulphur, 
best in so-called candles, for every thousand cubic feet of space 
are sufficient. When sulphur is burned, proper care should be 
taken to prevent fire; the burning sulphur should be placed in 
pans on islands surrounded by water, so that spitting of the 
burning sulphur cannot start a fire. There should also be 
steam from boiling water, or from a radiator, in the room for 
the best results of sulphur fumigation. Sulphur is the best 
disinfectant when lice, flies, or other insects may be the carry- 
ing source of the contagium. When there are no animal 
carriers of the particular disease, formaldehyde is the better 
fumigator. 

One of the best methods for causing formaldehyde fumigation 
is to dissolve 75 grams of permanganate of potash in 90 mils of 
hot water; then 30 grams of paraformaldehyde is added. This 
causes continuous liberation of formaldehyde gas until the 
formaldehyde has been exhausted, and this amount is sufficient 
for disinfection of a thousand cubic feet. Dixon has suggested 



DISINFECTION 



"5 



substituting the following for the above, namely : pour together 
a pint of a saturated solution of formaldehyde gas and one and 
a half ounces of strong sulphuric acid. When this mixture 
has become cooled the solution is poured over 10 ounces of 
sodium dichromate crystals which is spread out in a thin layer 
in a large container. 

No matter how thoroughly the fumigation is done, scrubbing 
and sunlight, if possible, should follow. 

Formaldehyde. — Liquor Formaldehydi. — Solution of Form- 
aldehyde (Formalin) is best procured in sealed bottles. The 
strength of the official preparation is 37 per cent. Formalde- 
hyde solutions should never be used internally. 

Action. — The local action of a strong formaldehyde solution 
is irritant and painful, and if it is applied to the skin in full 
official strength, it must be quickly washed off or it will cause 
blistering. Even if weak solutions, as 2 or 3 per cent., are used 
repeatedly on the skin it will cause irritation, eczema, and per- 
haps dermatitis. It has been considered that 1 and 2 per cent, 
solutions were actively germicidal if the germs were subjected 
to the action of such solutions for an hour or more, but Hatcher 
and Wilbert state that it requires forty-five minutes for de- 
struction of tubercle bacilli in a 5 per cent, solution. If the 
solution is hot, it acts more rapidly. 

Toxic Action. — If formaldehyde gas is inhaled it is so irritant 
that it may cause swelling of the larynx, edema of the glottis, 
and suffocation. The gas, even in small amounts, will seriously 
irritate the nose, throat, and larynx, and cause reddening of the 
eyes. If a solution of formaldehyde (unless it is very weak) is 
taken into the stomach, it will act as an irritant poison and 
cause the usual symptoms of such a posion. If a very 
weak non-irritant solution is taken into the stomach it will 
retard digestion. If much of this substance is absorbed into 
the blood it may break up the hemoglobin and cause hemoglo- 
binuria, and if very much is absorbed, nephritis may be caused. 

Treatment of Poisoning. — When strong solutions are taken 
into the stomach the treatment is that of an irritant poison (see 
page 757). If there are signs of edema of the glottis from in- 
halation of the gas, intubation or tracheotomy must be done. 



Il6 THE PRINCIPLES OF THERAPEUTICS 

Uses. — The use of formaldehyde as a disinfectant has already 
been described (see page 114). In a tightly closed room, and 
kept closed for twenty-four hours, sheets wet with 150 mils 
of the official solution of formaldehyde is sufficient for disinfecting 
one thousand cubic feet of space. Hatcher and Wilbert cau- 
tion that for this kind of formaldehyde disinfection to be effi- 
cient and successful, the temperature of the room must not be 
below 6o° F. 

Solutions of formaldehyde may be used in full strength to 
destroy a wart, and to destroy such a skin infection as ringworm, 
especially ringworm of the legs. As soon as it begins to cause 
pain and burning, the part should be quickly washed with water, 
else a dermatitis will be caused. Weaker solutions may be 
applied to the skin every two or three days in various parasitic 
diseases. It is sometimes efficient in a 2 per cent, solution 
when applied every night for a short time to disagreeably 
smelling feet and axillae. It tends to inhibit the sweat glands, 
and also destroys the disagreeable odor. Clothing and in- 
struments may be disinfected by formaldehyde fumes, but for- 
maldehyde solutions corrode instruments. 

Ten per cent, solutions of formaldehyde are efficient in dis- 
infecting such excreta as sputum, urine and feces, provided they 
are subjected to these solutions for at least an hour. 

Paraformaldehyde (Paraformaldehydum) — Paraf orm occurs 
as a white solid or powder, which on heating liberates form- 
aldehyde gas. It is antiseptic and irritant, and may be used 
as an escharotic to remove warts or other tissue. It should 
not be used internally. 

ANTISEPTICS 

One of the strongest antiseptics is the bichloride of mercury, 
and it is germicidal even in a solution of 1-25,000 or even weak- 
er, but the strength of solution most frequently used for 
external antisepsis is from 1-2,000 to 1-1,000. Corrosive subli- 
mate should not be used on instruments, and if used frequently 
on the hands it causes a dermatitis. When it is added to sub- 
stances containing albumin, as the feces, it forms an albuminate 
which interferes with its germicidal efficiency. Tartaric acid 



ANTISEPTICS 



117 



prevents this reaction, and this acid is added to bichloride anti- 
septic tablets. The number of tablets required to make the 
various strengths of mercuric chloride solutions is indicated on 
the bottles containing them. 

On account of the frequency with which bichloride of mercury 
poisoning has occurred accidentally, the tablets are now colored 
blue or red and labelled "poison;" or they are made in triangu- 
lar or diamond shape. Therefore there seems no excuse but the 
grossest kind of carelessness for mistaking these tablets for any 
other kind of tablets. The official tablets termed Toxitabellce 
Hydrargyri Chloridi Corrosivi contain about one-half a grain 
each of mercuric chloride and sodium chloride. 

Mercuric Oxycyanide is a strong antiseptic and does not act 
on albumin as much as does mercuric chloride. It may also 
be used to sterilize instruments without corroding them. As 
an external antiseptic it is used in the strength of 1-5,000 to 
1-3,000. 

Schamberg, Kolmer and Raiziss 1 have shown that Mercuro- 
phen (sodium oxymercuryorthonitro phenolate) is fifty times as 
active as mercuric chloride against the staphylococcus aureus, 
and it destroyed these bacteria on prolonged exposure in bouillon 
in a dilution of 1 part to 10 million. It was found to show many 
thousand times greater germicidal power against the typhoid 
bacillus, and to disinfect the hands in 1 part to 10,000 to 1 part 
to 40,000 in one minute, as compared with mercuric chloride, 
which required five minutes to disinfect the hands in the 
strength of 1 part to 5,000, and fifteen minutes in a dilution of 1 
part to 10,000. This preparation was found to sterilize rubber 
tubing in thirty minutes in a dilution of 1 part to 100,000. It 
was found to sterilize the feces in thirty minutes in 1 part to 
5,000. Nickle-plated instruments after twenty-four hours' 
exposure in 1 part to 5,000 of this mercurial salt showed no 
tarnishing. 

Macfarlan 2 finds that potassium mercuric iodide is a distinct 
chemical entity, is a salt that is delequescent, and upon taking 
up water readily deposits red mercuric iodide. This salt is 

1 Journal A. M. A., May 19, 191 7, p. 1458. 

2 Amer. Journ. Med. Sci., April, 1920, p. 586. 



IlS THE PRINCIPLES OF THERAPEUTICS 

most conveniently used in tablet form for antiseptic purposes. 
It is soluble in both water and alcohol. It is much less toxic 
than mercuric chloride, and therefore is safer for germicidal use 
in parts from which it could be absorbed. Macfarlan finds 
that J 2 t° 1 P er cent - solutions are slightly irritating to mucous 
membranes, but solutions of such a strength have no irritating 
effect on the skin. Potassium mercuric iodide is a powerful 
germicide even in high dilutions, and he found that it kills 
many organisms after prolonged exposure, even in dilutions of 
i part to 80,000. 

This double iodide has been found efficient as a disinfectant 
for the skin in the strength of 1 per cent, in 70 per cent, alcohol. 

Phenol solutions are expensive, require for thorough germi- 
cidal purposes to be 5 per cent, in strength, are benumbing to 
the hands, more or less irritant, and are now rarely used. 

Labarraque's Solution {Liquor Soda Chlorinatce) is effici- 
ently germicidal and is especially valuable in removing bad 
odors. Dakin's solution is a chlorinated lime solution. Both 
it and the Daufresne's modification of it are difficult of prepara- 
tion. Consequently, except in hospital service, a chlorinated 
solution is more readily made with the so-called "Dichloramine- 
T" tablets. The number of tablets to be dissolved in 100 
mils, or in 500 mils (a pint) of water is designated on the bottle; 
the strength of solution for injection is generally 1 or 2 per cent. 

Chloramine-T (Sodium Paratoluenesulphochloramide) is a 
stable chlorinated soda antiseptic, and is used in 1 to 2 per cent, 
solutions in the same manner that Dakin's solution is used. 
Dichloramine-T (Paratoluenesulphodichloramide) is a little 
more irritant than the chloramine-T, but it is more soluble. 
Various chloramine-T and dichloramine-T preparations are on 
the market. 

For disinfection of small quantities of water Dakin found 
most efficient and satisfactory parasulphondichloraminobenzoic 
acid. This substance can be obtained in tablet form ready for 
use under the name of "Halazone." 

The official Liquor Formaldehydi, diluted one part to one or 
two thousand, may be used as an antiseptic wash, but even such 
weak solutions are irritant and soon cause irritation of the skin. 



STERILIZATION H9 

The tincture of iodine painted thoroughly over the skin, 
provided the skin is dry and has not been recently moistened, 
is one of the best germicides that we possess. It seems to 
positively render sterile the region to which it is applied, and it 
is now used to sterilize the skin for surgical incisions. This is 
the age of using too much iodine, especially in the mouth, and 
the laity with a little knowledge of first aid to the injured 
use iodine too frequently. Many times it injures the tissues 
and prevents healing. 

Peroxide of hydrogen solutions in full strength or diluted 
depending entirely upon the part to be treated, are efficient 
antiseptics, but they should never be used in cavities or sinuses 
where there is any possibility of the bubbles of gas causing 
dissection or tearing of the tissues. 

The official Cresol is a mixture of cresols, and is a valuable 
antiseptic in 3 to 5 per cent, solutions. Iodoform is not 
an antiseptic and never should be considered such, although it 
may at times prevent germs from growing. 

Churchman, 1 after repeatedly urging the antiseptic value of 
gentian violet since 191 2, again states that, even in high dilutions, 
this drug has great antiseptic value in long continued suppura- 
tions in old wounds, and, where the bacillus diphtheria was the 
infection, gentian violet properly applied killed the infection 
and caused healing. He also 2 shows its effective antiseptic 
action, combined with lavage, in purulent arthritis. 

STERILIZATION 

Not to enter into the discussion of sterilization of instru- 
ments and dressings, it should be emphasized that intense dry 
heat, boiling water, and steam, applied for one-half hour or 
more, are the most efficient sterilizing means known, and make 
possible our present day aseptic surgery. 

Phenol. — Carbolic Acid. — Phenol crystals are used only for 
escharotic purposes. The official preparations of phenol are 
Glyceritum Phenolis and Phenol Liquefactum which occurs either 
as a colorless or slightly reddish liquid and should contain not 

1 Journal A. M. A., Jan. 17, 1920, p. 145. 

2 Journal A. M. A., Aug. 28, 1920, p. 583. 



120 THE PRINCIPLES OP THERAPEUTICS 

less than 87 per cent, of phenol. The official Unguentum Phe- 
nol is contains 2 }i per cent, of liquefied phenol. Phenol, carbol- 
ic acid, is obtained from coal-tar by fractional distillation, but 
it may also be made synthetically. Neither phenol nor any 
of its preparations should be used internally. 

Action. — When liquefied phenol is used in full strength, or 
nearly full strength, it blanches the skin and mucous membranes, 
causes a sharp, burning pain, soon followed by dulling of sensa- 
tion. In other words, it causes localized anesthesia. It may 
or may not blister with one application, but the part to which 
it is applied turns white, and if the application is longer than 
momentary, the part becomes necrotic, and continued appli- 
cations of even weak solutions will cause gangrene. Hence it 
is inexcusable to keep a part wet with phenol solutions. 

Except in weak solutions it is irritant to the skin and mucous 
membranes. In 10 per cent, solutions, applied to a part for a 
short period, it causes considerable anesthesia, and incision 
may be made through the skin in this region without pain ; but 
other methods of producing local anesthesia for operative pur- 
poses are better. Frequent applications of even weak solutions 
to the skin will cause eczema, and perhaps dermatitis. On the 
other hand, solutions as weak as 2 per cent, may soothe an 
irritated and inflamed region, but if the surface is denuded of 
skin, dangerous absorption may occur. Other preparations 
for soothing the skin and stopping itching are better. 

Toxic Action. — When this drug is absorbed in a small amount, 
it is irritant to the central nervous system, causing headaches, 
irritability, restlessness, and muscle twitchings. The digestion 
is slowed, and vomiting and purging may occur. The urine 
becomes dark, if much of the drug has been absorbed; there is 
irritability of the bladder, urination becomes more frequent, 
and albumin may appear in the urine. Soon, if more phenol 
has been absorbed, the circulation and respiration are depressed. 

If a considerable amount has been rapidly absorbed the 
symptoms are those of collapse and drowsiness. The pulse be- 
comes weak and thready, the face pale, the skin covered with 
clammy perspiration, and muscular twitchings occur. If the 
patient long survives the poisoning, there may be suppression of 



STERILIZATION 121 

urine. If a very large dose has been taken and there has been 
rapid absorption, coma sometimes occurs within a few minutes, 
and death soon follows. When death is not immediate, there 
may be convulsions, or at least muscular twitchings, generally 
nausea and vomiting, lowered temperature, and weak heart 
action. If the preparation was strong, there is erosion of the 
esophagus, and perhaps of the stomach, if enough of the fluid 
was taken to reach the stomach. 

The brown or black urine is caused by the formation of 
hydroquinone and pyrocatechin. When this urine is first 
passed it may not be very dark, owing to incomplete oxidation, 
but when it is exposed to the atmosphere for a time oxidation 
becomes more complete, and the urine becomes dark brown or 
black. Albuminuria is often present, and acute nephritis may 
occur. 

When small amounts of phenol are frequently absorbed, or 
coal-tar products are long taken, chronic poisoning occurs, evi- 
denced by anemia and cardiac depression. 

Treatment of Poisoning. — Whether or not the stomach tube 
should be passed depends upon the amount of the poison that 
has been taken. When much concentrated phenol has been 
swallowed, as in any other irritant poisoning, a stomach tube 
should not be used on account of the injury that would 
be caused. 

The treatment of phenol poisoning is not very satisfactory. 
The best method seems to be, as recommended by Hatcher, 
to immediately give raw white of egg in considerable amount, 
diluted sufficiently for swallowing. Then if the stomach tube 
can be passed, the stomach should be washed out immediately 
with water containing 10 per cent, of alcohol. If the stomach 
tube cannot be passed, and the patient can swallow, this alco- 
holic water should be given him as a drink. Magnesium sul- 
phate and sodium sulphate have both been recommended, as 
tending, when given in solution, to form harmless phenosul- 
phonates, but their usefulness is doubtful. 

Emetics are not indicated and would do harm, as the cardiac 
prostration is serious. Oils should not be given, as they may 
promote more absorption. 



122 THE PRINCIPLES OF THERAPEUTICS 

Later, if the patient survives, all the soothing applications 
that are recommended under irritant poisoning should be 
utilized. Cardiac failure should be treated as usual, and 
adrenalin and pituitary vasopressor solutions, injected hypoder- 
ma tically , are perhaps most indicated. Atropine is also valuable. 
The patient should be surrounded by hot water bags, on account 
of the lowered temperature. 

Uses. — As above stated, there is no good reason to use phenol, 
as such, internally. Externally it may be used as an antiseptic 
and as a parasiticide. It is occasionally valuable as a local 
anesthetic and as an escharotic, and it is used not infrequently 
to abort boils and carbuncles. Two or three drops of Phenol 
Liquef actum injected into the base of a furuncle or boil will 
often abort it. 

Its use as an antiseptic has already been discussed under the 
general heading of "Antiseptics." While bacterial growth is 
inhibited by a i per cent, solution, it requires stronger solutions 
and some length of time of emersion to destroy all bacteria. 
In other words, most infective germs are probably destroyed 
by emersion for an hour in a 5 per cent, solution. 

As a parasiticide, in strong solutions, it is efficient, but 
the surface to which it is applied should be small, as dangerous 
absorption may occur. 

Preparations containing phenol, so-called coal-tar prepara- 
tions, should not be used when there is cardiac weakness, 
insufficiency of the kidneys, or cerebral irritation. 

Cresol. — The official preparation is a mixture of cresols. It is 
less poisonous than phenol, although its action is similar. It 
is about four times as active a germicide as is phenol, and is 
efficient in solutions of 1 per cent. The official preparation, 
Liquor Cresolis Compositus, is efficient as a wash for wounds, 
or for douches, in the strength of 1 to 5 per cent, solution in 
water. 

Hydrogen Dioxide. — Liquor Hydrogenii Dioxidi. — Solution 
of hydrogen dioxide contains 3 per cent, of hydrogen dioxide. 
This preparation rapidly deteriorates on exposure to light 
and heat, and from opening the bottle or container, the 
liquid becoming more or less irritant. Consequently, it is 



STERILIZATION 1 2 3 

generally best to order an original small bottle, to be diluted, 
just before using, to such strength as desired. Solution of 
peroxide of hydrogen is not much used internally, although it 
has been recommended in certain conditions of the stomach for 
its antiseptic properties, to prevent hyperacidity, and some- 
times to stop oozing of blood from the esophagus or stomach. 

The chief uses for this preparation are in certain conditions in 
the mouth and throat, and externally. 

Action. — The solution of hydrogen dioxide should be colorless 
and odorless; it generally has a slightly acid taste, and causes 
frothing of mucus, blood, and pus. This solution is destructive 
to microorganisms and spores, and in sufficient amount will 
purify drinking water. It tends to coagulate albumins, and 
hence has a slight hemostatic power on bleeding surfaces. Its 
antiseptic action is rapid; as soon as it has lost its extra atom of 
oxygen its action ceases. 

It is more or less irritant to both mucous membranes and raw 
surfaces, hence within a few minutes after the peroxide solution 
has been used, the part should be washed with plain warm water 
or with some alkaline water. On account of its irritant effect it 
should not be used on acutely inflamed mucous membranes or 
on raw surfaces except when its antiseptic action is desired. 
It should never be injected into a closed cavity or into a sinus, 
as the gas produced causes dissection of tissue and pre- 
vents healing. It should not be used as a disinfectant for 
instruments. 

When taken into the stomach it has no action except to give 
up its oxygen. If the solution is strong, it may cause distress 
and nausea, but it cannot cause poisoning. 

Uses. — Although there may be occasions, especially in 
gastric cancer, when peroxide of hydrogen solutions may be 
administered internally, there is no good reason for using 
this preparation in any way except externally. 

As an antiseptic mouth wash, in diphtheria, scarlet fever, 
follicular tonsillitis, and other mouth infections, it is one of 
the most valuable of preparations. It may be used in full 
strength as a spray on localized regions, but it is better used as 
a mouth wash or gargle diluted one to three, four, or five parts 



124 THE PRINCIPLES OF THERAPEUTICS 

of warm water, depending upon the age of the patient and the 
purpose for which it is used. In follicular tonsillitis, in diph- 
theria, and in the tonsillar inflammation of scarlet fever it 
should be used as a swash {i.e., not to vibrate the soft palate too 
frequently or too long) every one and a half to three hours, 
depending upon the severity of the condition, generally, every 
two hours during the daytime and every three or four hours 
during the night. Such gargling or washing should be followed 
within two or three minutes with such an alkaline wash as Y± of 
a teaspoonful of salt and J^ °f a teaspoonful of bicarbonate of 
sodium in Y 2 a glass of warm water, or by a saturated solution 
of boric acid, or by any of the simple alkaline mouth washes. 
As above stated, the object of this second sedative wash is to 
clear the membrane of froth and of the acid irritation which the 
peroxide of hydrogen causes. 

Peroxide of hydrogen solutions should not be used as a gargle 
every time the throat feels irritated, as it tends to continue such 
irritation. In purulent conditions of the gums it may be used 
for a time until surgical cleanliness has been accomplished, but 
it should not be used in the pockets dipping down to the roots 
of teeth, as it tends to dissect the tissues. Other antiseptic 
washes for these conditions, especially saturated boric acid 
solutions, are better. 

Sprays and douches with peroxide of hydrogen solutions in 
the nose are of questionable value. They are likely to do as 
much harm as good. 

It is a valuable germicidal wash in various conditions of the 
skin, although other preparations are generally better. It may 
be used to disinfect fresh wounds, but the tincture of iodine is 
the more popular remedy, although perhaps not more efficient. 
It should not be frequently used on ulcers or ulcerated surfaces, 
as it tends to prevent healing. 

It has been used to wash out the bladder, urethra, and vagina, 
but other solutions are better for these purposes. It has also 
been injected into the rectum and into the descending colon in 
parastic or ulcerated conditions, sometimes with considerable 
apparent success. Wherever it is used as an injection it must 
be followed by other soothing injections. 



EXTERNAL ACTION ON SKIN 1 25 

PARASITICIDES 

To show how large a choice of these preparations the United 
States Pharmacopoeia offers, besides the stronger antiseptics 
and escharotics, the following list is given in their alphabetical 
order : 

Balsamum Peruvianum 

Betanaphthol 

Glyceritum Phenolis 

Hydrargyrum preparations 

Linimentum Saponis Mollis 

Phenol Liquefactum 

Pyrogallol 

Sulphur 

Tinctura Iodi 

Resorcinol 

Trinitrophenol (Picric Acid) 

Unguentum Chrysarobini 

Unguentum Picis Liquidae 

Unguentum Sulphuris 

With this list of preparations that may be used as para- 
siticides it would seem entirely unnecessary to resort to 
proprietaries. 

CLASS II 

Drugs Used Externally for Action on the Skin 

Before local treatment of an abnormal condition of the skin 
is instituted, the cause should be sought, which may be a drug, 
a food, or some protein poison (see list of drugs that cause erup- 
tions, page 43; and see article on protein poisoning, page 553). 
Or the cause may be some disturbance of metabolism, typically 
of the digestion of proteins. Hence the primary treatment of 
irritations of the skin is to limit the intake of drugs and foods; 
purge with salines, castor oil, or calomel; give large amounts of 
water; and often administer alkalies. The secondary treat- 
ment should be directed toward the skin. 

If local or external irritants have caused the inflammation 



126 THE PRINCIPLES OP THERAPEUTICS 

of the skin, the local treatment is primary; but a modification of 
the diet and free bowel movements, even in such a condition, 
are valuable secondary treatments. 

When the skin is acutely inflamed, it should not be bathed 
with water, but should be cleansed with some bland, thin oil, as 
almond oil. All skin irritations are made worse by cold water, 
but are soothed by warm water, especially if to the warm water 
is added sodium bicarbonate, boric acid, or borate of soda. 
Water is made irritating and stimulating by the addition of sea 
salt. 

The amount of surface to be treated by external applications 
must always be considered, for a large area would permit ab- 
sorption of an absorbable drug to an extent which a small area 
could not. The situation of the lesion must also be taken into 
consideration, for this not infrequently decides whether (if the 
cause be inherent to the skin itself) we shall use a strongly acting 
preparation for a short time, or a milder one for a long time. 

DUSTING POWDERS 

Dusting or protective powders are used to meet the following 
conditions: 

i. Erythema ta in general, and particularly in erythema 
intertrigo (chafing) and erythema solare (sunburn). 

2. Hyperidrosis and bromidrosis (excessive and foul smelling 
perspiration) . 

3. Herpes. 

4. Miliaria. 

5. In certain forms of eczema which are acute and free from 
discharge. 

The official powders that prevent irritation of the skin, soothe 
irritated surfaces, and prevent excessive secretion of the skin 
are: 

Acidum Boricum (boracic acid) 
Acidum Tannicum 
Alumini Hydroxidum 

(Alumnol, not official) 
Amylum (corn starch) 



DUSTING POWDERS 127 

Bismuth preparations 

Calcii Carbonas Praecipitatus (precipitated chalk) 

Creta Praeparata (prepared chalk) 

Iodine preparations 

Lycopodium 

Magnesii Oxidum (magnesia) 

Sodii Boras (borax) 

Zinc preparations 

Starch, fuller's earth and kaolin are good simple dusting 
powders. 

Bismuth Preparations. — The best preparation of bismuth for 
external use is the subgalate (derma tol). This is a yellow 
insoluble powder, which is more astringent than the other bis- 
muth salts. Bismuth subnitrate should not be used on moist 
external surfaces, especially not on blistered surfaces, as bismuth 
poisoning can occur from such applications. It is less likely to 
occur when the subcarbonate is used. 

Boric Acid. — Boric acid is not as drying as other powders, 
adheres to surfaces, and is mildly antiseptic. On moist sur- 
faces it tends to promote rather than diminish secretions. 
Borax acts similarly to boric acid. Both preparations are very 
valuable, in saturated solutions, as mild antiseptic washes for 
any mucous membrane, and they tend to promote healing of all 
ulcerated surfaces and to promote the healing of wounds. 
Most talcum powders have boric acid as a base. 

When boric acid or borax is taken internally poisoning may 
occur. There is no excuse or justification, or any good indica- 
tion for administering internally either boric acid or its sodium 
salt. 

Iodine Preparations. — Iodine powders are more or less germi- 
cidal and more or less protective. Large numbers of proprie- 
tary preparations are offered, and the official Thymolis Iodidum 
when well made, is a valuable drying, mildly antiseptic powder 
and often is an aid in the healing of wounds. This preparation 
contains 43 per cent, of iodine. 

Iodoform. — Iodoform is a bad smelling, yellow powder, mildly 
antiseptic but not germicidal. There is no excuse for using 



i:S THE PRINCIPLES OF THERAPEUTICS 

this drug internally, and it is absolutely unjustifible to use it 
externally on account of its obnoxious odor. It may be used in 
emulsion in oil as an injection into a tuberculous joint or tendon. 

Ly co podium. — This light, yellow, odorless powder is soothing, 
and is much used as a dusting powder on excoriated surfaces. 

Zinc Preparations. — The most used are the precipitated car- 
bonate, the oxide, and the stearate. The impure zinc carbonate 
is termed calamine. The precipitated carbonate and the oxide 
are excellent protective dusting powders. The zinc oxide is 
slightly astringent, and is most frequently used as the oxide of 
zinc ointment. The stearate of zinc has a soapy feel, is more 
adherent to the skin, and, therefore, gives protection against 
watery secretions or excretions passing over the part. 

Alumnol. — Aluminum betanaphtholsulphonate is a white 
powder, soluble in water. It is astringent and an antiseptic 
even in i per cent, solutions. When used as a powder it is 
generally diluted with some bland substance, as starch or 
chalk. 

Fuller's Earth. — Hess 1 has shown that there is a distinct 
difference between kaolin and fuller's earth, kaolin having a 
greater amount of hydrous aluminum silicate, and fuller 's earth 
having considerable more calcium. Fuller's earth has greater 
drying properties than kaolin, and therefore is efficient as a dry- 
ing powder for external use, and also has been found of value for 
internal use in intestinal disturbances of children. Hess recom- 
mends for diarrhea of infants the administration of a teaspoonful 
of the powder, either in milk or in some other food, every hour or 
two. Sometimes to facilitate administration he adds a very 
small dose of saccharin. He thinks the powder of more value 
in inhibiting diarrhea than bismuth or chalk mixture. The 
powder may also absorb bacteria. Fuller 's earth may be found 
more valuable than kaolin for insufflation in the throat in 
diphtheria carriers. 

EMOLLIENTS 

Emollients are bland oily or fatty substances which, though 
generally devoid of medicinal properties, are more or less 
mechanically sedative when applied to the skin. The method 

1 Journal A. M. A., Jan. 8, 1916, p. 106. 



EMOLLIENTS 120, 

of application varies with the conditions for which they are used. 
The indications for the use of emollients are : 

i. To aid massage. 

2. To soften a dry skin. 

3. To soothe chafed or excoriated surfaces. 

4. To protect the skin from irritating discharges. 

5. To soothe and protect burned areas. 

6. To soothe in acute eczema and dermatitis. 

The large number of oily substances offered as soothing appli- 
cations to the skin are entirely unnecessary ; a few well selected 
preparations are sufficient. Organic (animal and vegetable) 
fat substances will become rancid and harbor microorganisms 
unless they contain a sufficient amount of an antiseptic. The 
mineral oils do not become rancid, and although not germicidal 
do not promote the growth of bacteria. Which kind of fat is 
best for a given condition or for an individual skin must be 
decided by the physician, namely: whether a mineral, vegetable, 
or animal fat shall be used. It does not seem logical to com- 
bine mineral and organic fats in the same ointment or 
preparation. 

The Pharmacopoeia prepares cerates and ointments. The 
former are harder preparations with a melting point higher than 
the temperature of the body, while the ointments are softer and 
generally melt at the temperature of the body. 

Some of the various fatty soothing preparations of the Phar- 
macopoeia are: 

Adeps Benzoinatus (benzoinated lard) 

Adeps Lanae Hydrosus (lanolin) 

Oleum Gossypii Seminis (cottonseed oil) 

Oleum Lini (linseed oil) 

Oleum Olivae (sweet oil) 

Oleum Theobromatis (cacao butter) 

Petrolatum (vaseline) 

Petrolatum Album (white vaseline) 

Petrolatum Liquidum 

Unguentum Acidi Borici 



130 THE PRINCIPLES OF THERAPEUTICS 

Unguentum Acidi Tannici 
Unguentum Aquae Rosae (cold cream) 
Unguentum Belladonnas 
Unguentum Zinci Oxidi 

Some of the Pharmacopceial liquid preparations that are 
soothing to the skin are: 

Aqua Hamamelidis (extract of witch hazel) 

Glycerinum 

Glyceritum Acidi Tannici 

Glyceritum Boroglycerini 

Linimentum Calcis (carron oil) 

Liquor Ferri Subsulphatis is sometimes used as a strong 
astringent on external surfaces. 

Liquor Plumbi Subacetatis, diluted to 5 per cent, in water, 
may be used as a sedative on the skin when absorption cannot 
take place. 

Simple collodion and flexible collodion will protect a part, but 
it should be emphasized that broken skin lesions should never 
be sealed with collodion or in any other manner, even if surgi- 
cally clean, as such sealing prevents normal respiration of the 
skin, sweats and softens the tissues, delays healing, and promotes 
infection. 

Picric Acid (Trinitrophenol) is used in saturated solution in 
water, or in ointments, as a dressing for burns. 

Ichthyol is used as a mild stimulant in certain conditions of the 
skin. 

Ichthyol. — Ichthyol is a thick brown oily liquid obtained by 
the distillation of bituminous shales which contain fossil fish. 
The name "ichthyol" signifies fish oil. Ichthyol occurs 
mostly as ammonium ichthyo-sulphonate, which has a 
distinct fishy odor and taste. A sodium compound, sodium 
ichthyo-sulphonate, is more solid than the ammonium prepara- 
tion and has been more used in the preparation of pills or 
capsules for internal administration. Both preparations con- 
tain about 10 per cent, of sulphur. 

Ichthyol, in various forms, has been recommended for 



EMOLLIENTS I3I 

internal administration as a bowel antiseptic, and as such has 
been much used in disturbances supposed to be caused by 
intestinal fermentation and putrefaction. For this reason it 
has been recommended and used in acne. It is doubtful if 
for this condition it is of any more benefit than other sulphur 
preparations, combined with a proper arrangement of the diet. 
Ichthyol has also been recommended for internal use in tuber- 
culosis. Any advantage that it might have in this disease 
is probably due to the action of the sulphur on the bowels and, 
after its absorption, on the skin and possibly by such 
exhalations of sulphur as may occur through the lungs, i.e., 
the action is probably nothing but that of sulphur. 

When ichthyol is administered internally generally the 
sodium salt is preferred, and the dose is from 0.25 to 0.50 Gm 
(4 to 7^ grains), in capsule, three times a day, after meals. 
When used for tuberculosis ichthyol has been diluted with 
water, and the dose has gradually been increased up to the 
point of causing indigestion. 

Externally ichthyol is used as an ointment, or in combination 
with an oil or glycerin, and the strength of the preparations 
vary from 10 to 50 per cent. 

When ichthyol is applied undiluted to the skin it is an irritant. 
When it is combined with an oil, or a fat, it can be rubbed into 
the skin, and some of the sulphur may be absorbed. It may 
have a mild antiseptic action.' 

Though ichthyol is not as much used as it was some few years 
ago, it is still considered a valuable application in erysipelas, 
for sprains and swollen joints, for frost bites, chilblains, and 
for burns. It is well used in 25 per cent, ointment, or solution 
in either water or oil. In subacute swellings of the lymphatic 
glands applications of ichthyol ointment, 10 to 20 per cent., 
or in the same strength in glycerin or oil, have seemed to hasten 
the reduction of the swelling. This preparation has also been 
used in many skin diseases, especially in acute and chronic 
eczema. It has been used as suppositories for hemorrhoids and 
fissures of the anus, and has been much used as suppositories, 
or applications on tampons, in the vagina for chronic conditions 
of the pelvis and neck of the womb. 



132 THE PRINCIPLES OF THERAPEUTICS 

Ichthalbitij N.N.R. 1 — Ichthyol albuminate is a compound of 
ichthyosulphonic acid and albumin. This solid preparation is 
used in place of ichthyol for internal purposes, and is less likely 
to disturb the stomach than the latter. The dose is 0.30 Gm. 
(5 grains). 

Inunctions. — By inunction is understood rubbing into and 
through the skin some drug that is dissolved or contained in an 
oil or fat. Systemic effects may be produced by such a method 
of administration with a few drugs only, notably mercury and 
belladonna. The parts of the body best adapted for this 
method of administration are where the skin is soft and flexible, 
as the inner surfaces of the thighs and the inner surfaces of the 
arms. This method is rarely utilized except for the adminis- 
tration of mercury in syphilis. 

Antiseptic Ointments. — For local stimulation of a chronically 
diseased portion of the skin, the following Pharmacopceial 
preparations may be used: 

Balsamum Peruvianum 
Oleum Cadinum 
Pyrogallol 

Unguentum Chrysarobini 
Unguentum Iodi 
Unguentum Picis Liquidae 

One of the most important non-official preparations for 
stimulation of a chronic ulceration is Scarlet Red, (N.N.R.,) as 
it is termed. This preparation is a compound of betanaphthol 
and toluol, and occurs as a red ointment, which promotes the 
healing of ulcers, wounds, and burns. 

COUNTERIRRITATION 

Counterirritation means to so irritate a part of the surface 
of the body as to cause reflexly a modification of a condition in 
another part of the body, generally at some distance from the 
part irritated. The term is often used to indicate local irrita- 
tion for local results. 

1 New and Nonofficial Remedies, a book of drugs issued by the American 
Medical Association. 



COUNTERIRRITATION 1 33 

Various ointments may be used for local stimulation or for 
their reflex or irritant action. Some are used only to increase 
the value of massage. The least irritant of the liniments is 
Linimentum C amphora (camphorated oil). Linimentum Sapo- 
nis Mollis (soft soap) is used for cleansing purposes and for 
shampooing; it is strongly alkaline. 

The official stimulating liniments are: 

Linimentum Ammonias 
Linimentum Camphorae 
Linimentum Chloroformi 
Linimentum Saponis 
Linimentum Terebinthinae (a cerate) 
Menthol (in solutions) 

Methylis Salicylas (synthetic oil of wintergreen) 
Oleum Terebinthinae Rectificatum (used as an addition 
to liniments). 

If the irritation from liniments goes a step farther, blistering 
may be caused, and if still farther, destruction of tissue occurs. 
Blistering for a reflex effect on some other part of the body is 
often practised. Destruction of tissue (causing a slough) to 
cause reflex action on some distant part is now rarely or never 
caused. For local effect, or at least for effect on the tissues 
closely associated with the part treated, the stimulating (rube- 
facient) liniments are frequently used. At the present time the 
benefits caused by counterirritation are probably not suffi- 
ciently utilized. 

Two effects are combined when a liniment is properly used: 
first, the massage, and second, the local irritation and hyperemia 
of the skin that is caused. The massage improves the circula- 
tion and nutrition of the part, and often is the factor of greatest 
advantage in the use of liniments; but the hyperemia of the 
skin may change for the better the circulation of the parts imme- 
diately beneath the skin or the parts closely associated with the 
part treated. Chloroform and menthol preparations may cause 
the, part treated to feel cool, unless the skin is quickly covered 
and evaporation prevented after they are used. 

Blistering with liniments is inadvisable, as the blisters do 



134 THE PRINCIPLES OF THERAPEUTICS 

not readily heal, and the process is more painful than when the 
Spanish fly blister is used. 

The value of dry heat applied to a part, whether by hot water, 
sand, salt, or bran bags, or by various hand stoves or electric 
pads, is very great, and many a surface nerve pain, or more 
deeply seated inflammation, is helped by such treatment. 
Moist applications of heat by hot water or hot water and alcohol 
are also valuable in certain conditions. The old-fashioned 
poultice is now rarely used, but may have its place. A sub- 
stitute is hot water and alcohol: — a towel wet with one part of 
alcohol and three or four parts of hot water, then a hot water bag 
placed over it, and the combination applied closely to the body. 

Mustard is a very efficient coimterirritant. It may be applied 
as a mustard paper, which is moistened and applied directly 
to the skin or with a thin piece of gauze between it and the skin. 
Or a mustard plaster may be made with equal parts of mustard 
and flour (or perhaps better with flaxseed meal instead of flour) 
which is efficient. This mixture of mustard and flour, or flax- 
seed meal, should be stirred to a paste with warm (not hot) 
water, then the paste is spread on a piece of cloth and 
applied to the skin; or it may be placed in a cheesecloth bag. 
This paste should be left on the skin from fifteen to thirty 
minutes, but not long enough to blister. For a thin-skinned 
individual and for a child the proportional strength of the mus- 
tard to the flour should - be greatly diminished. Some stiff 
background for this improvised poultice, as a piece of stiff 
paper, facilitates the handling of the plaster. It should be 
emphasized that blistering from mustard is inadvisable and 
should be avoided if possible, as the blister is painful and hard 
to heal as compared with blisters causes by cantharides. 

A plaster that will not blister, but at the same time will have 
some of the stimulating effects of mustard, hence best for a 
child, is made of spice, and may be compounded with equal parts 
of ground cloves, cinnamon, allspice, and a small portion of 
black pepper. This mixture having been stirred up with warm 
water is spread on a cloth, then the side to be applied to the 
body should be wet with hot water. If the child is young and the 
skin is very tender, the pepper should be omitted from the plaster. 



COUNTERIRRITATION 1 3 5 

A turpentine stupe is prepared by wringing out a piece of 
flannel from hot water, folding it several times, and sprinkling 
over it about half a teaspoonful of turpentine. This stupe 
should be applied closely to the part to be treated, generally the 
abdomen. 

All hot water fomentations and fomentations with alcohol and 
with turpentine should be applied as hot as can be borne, and 
be changed frequently, until the skin is well reddened. Then 
they should be removed and a dry, hot flannel should be applied. 
Blistering should not be allowed. If a blister inadvertently 
occurs from any of these treatments it should be treated like 
an ordinary burn. 

A milder treatment to cause reddening of the skin is furnished 
by capsicum ointments, which should be rubbed on the surface 
until slight irritation is caused. Various menthol preparations 
are also used. A menthol stick rubbed over the forehead, if 
there is headache, or over the region of some painful nerve is 
often beneficial. 

Iodine as an irritant to the skin is used too frequently. This 
is the iodine age. While all wounds with any possibility of 
infection may be treated with iodine, it should be remembered 
that it does not promote healing, and that frequent applications 
of it to a part that is trying to heal is a mistake. The skin over 
swollen glands, or the skin around a joint, may be painted, 
daily, with the tincture of iodine, if it is deemed advisable. Its 
use should be stopped before the skin becomes thick and leath- 
ery, and it should never be used to the point of causing a blister. 
Various iodine ointments may be used, and iodine may be 
rubbed through the skin and be absorbed. 

If a blister is desired, it is best produced by a plaster of can- 
tharides, which can be obtained at any drug store in the size 
desired. The skin to which the plaster is to be applied should 
be cleansed, and, if the part is hairy, it should be shaved. The 
active plasters that can now be obtained should not be kept on 
more than three or four hours; they should then be removed 
and a portion of the cerate from which the plaster is made will 
remain on the skin and cause blistering after some length of 
time, anywhere from five to six hours. If the object of the 



6 THE PRINCIPLES OE THERAPEUTICS 



blister is to remove considerable serum from the body, the blis- 
ter must be of fair size; if it is used for counterirritant 
action only, the blister may be small, or a series of small blisters 
a short distance apart may be applied. It is often well to drain 
off the fluid from the blister by a puncture at the lowest, de- 
pendent part, letting the fluid slowly exude. This allows the 
pellicle of skin to cover the raw surface and tends to promote 
healing. The cuticle should not be broken, if it is possible to 
prevent it, and it may be protected by linen, or thin cotton, well 
saturated with a sterile, thin oil, which should be removed before 
it becomes dry and adherent to the loose skin. If the skin is 
broken, the part is then treated as any other burn. Blisters 
should not be caused on young children, on old people, on any 
part where the nutrition and circulation is impaired, or on a 
paralyzed part. 

The blister is not now used as much for counterirritation as 
is the cautery, and the most used cauteries are the Paquelin or 
the electrocautery. The Paquelin is an apparatus which by 
burning benzine vapor causes a red or white heat of the terminal 
points, which may be of several different shapes. The white 
heat causes less pain than the red heat, but the red heat is better 
if a part is to be destroyed or cauterized, as it is less likely to 
allow hemorrhage. Light strokes of this cautery, or of the 
electrocautery, along the course of a nerve or around a painful 
joint is often of great benefit in neuritis and in inflammation of 
joints. 

Counterirritant treatment is based on the distribution of 
nerve filaments from different segments in the spinal cord, the 
different organs having reflex spots, or regions, on the 
surface of the body. When these organs are in trouble these 
particular external regions are generally painful and at times 
sore. Knowing the region that is a surface depot of information 
of the condition of a deeply seated organ gives the clue as to 
where the counterirritant should be applied to obtain a deep 
seated benefit. In other words, the circulation and nervous 
energy of an organ cannot be changed directly by what is done 
on a small part of the surface of the body, but both may be 
modified indirectly when the surface nerves transmit the irrita- 



COUNTERIRRITATION 137 

tion to its particular segment of the spinal cord, and reflexly 
that segment of the cord sends nervous stimuli to the organ in 
trouble. 

Many of our counterirritant effects need not have this ex- 
planation, if the part so treated is directly over or at the region 
of trouble; the local hyperemia and the nervous irritation caused 
may directly affect the part underneath, but typically through 
these spinal segments come the referred pains from these inter- 
nal organs, and sometimes counterirritation applied at these 
points acts reflexly to advantage. 

A blister should not be placed directly over an inflamed region, 
if that region is near the surface. In other words, a blister, 
in pericarditis should be placed at one side of the peri- 
cardium ; in a pleurisy a short distance away from the region of 
acute pain and with a painful joint generally above or below 
that joint. 

It is common knowledge that vomiting may be stopped by a 
mustard plaster, or other irritant, placed over the epigastric 
region ; that headaches, and even meningitis, may be beneficially 
affected by stimulant applications to the back of the neck; and 
that the kidneys may be influenced by heat in various forms 
applied to the lumbar region. 

In intercostal neuralgia the irritation, blistering, cautery, 
heat, diathermy, or whatever other application is advisable, 
should be applied at the side of the spine, at the point of exit 
of the nerve. The following combination may be used over 
painful joints and nerves: 

Chloral 5 Gm. 

Methyl salicylate 30 mils 

This should be rubbed over the painful part and the part then 
covered with waxed paper, rubber tissue or flannel. 

The nervous reflexes, especially the messages sent to the skin 
from disturbed inner organs of the body, should be more care- 
fully studied, and counterirritation should probably be more 
frequently used in medicine. 

The above discussion is only a brief outline of what the sub- 
ject means; but counterirritation, as well as other physical 



I38 THE PRINCIPLES OF THERAPEUTICS 

therapeutic measures, should not be neglected by the physician, 
and fewer patients will be treated by irregular practitioners. 

ESCHAROTICS 

An escharotic means a destruction of tissue; hence the drugs 
of this class are used for this activity. The destructive action 
is chemical, and consequently the tissue destroyed is limited by 
the amount of the drug used; namely, the destructive action 
ceases when a chemical union has taken place between the drug 
or preparation and the tissue. 

It is not now deemed good treatment to use strong caustics on 
hard chancres, in fresh wounds which may have been infected by 
the tetanus germ, or in dog or rat bites. Such cauterizations 
are likely to seal toxins and germs of infection within the wound 
and allow them to be absorbed and cause systemic poisoning. 
The best method is to constrict the circulation, if possible, 
above the bite, and to treat the lesion with a pure phenol 
solution. In snakebite the circulation above should be shut 
off, if possible, the wound sucked, and then perhaps best, 
freely incised to promote bleeding, and the wound filled 
with permanganate of potassium solution and the tissues 
above the wound perfused with strong permanganate solu- 
tions. Antivenine may be injected and ammonia given by the 
mouth. 

Escharotics are best used where small amounts of tissue are to 
be destroyed, as superabundant granulation tissue, and the 
semi-necrotic tissue of indolent ulcers; but modern surgery to- 
day rarely finds need for escharotics. 

The escharotics most used are the following: 

Chromium Trioxide. — Chromic acid occurs as small, purplish- 
red, brilliant crystals, which are soluble in water. This drug 
is used only as an escharotic, and in approximately a saturated 
solution. 

Glacial Acetic Acid. — This acid is a clear colorless liquid used 
in full strength as an escharotic. 

Trichloracetic Acid. — This acid occurs as colorless crystals, 
very soluble in water, it is used only as an escharotic. 

Nitric Acid. — This acid occurs as a clear liquid, the fumes of 



ESCHAROTICS 1 39 

which are irritating and should not be inhaled. It is used 
undiluted as an escharotic. 

Salicylic Acid. — This acid occurs as fine white crystals or 
powder, has a sweetish, rather burning, acrid taste, and is not 
very soluble in water. Externally it is an antiseptic, and in 
strong preparations escharotic. As an escharotic it is used to 
remove corns, warts, and callous skin. Its action is slow and 
painless. It may be applied as an ointment in 10 to 20 per cent, 
strength in petrolatum; or it may be used in collodion, 1 or 2 
Gm. to 30 mils. 

Silver Nitrate. — Nitrate of silver occurs as colorless crystals 
and is very soluble in water. Solutions turn black on exposure 
to light. A few drops of a 25 per cent, solution is especially 
useful in stimulating the healing process in ulcers, cankers, etc. 

Argenti Nitras Fusus. — Molded Silver Nitrate, (Lunar 
Caustic) is a hard white solid, generally prepared in pencils, 
and used as an escharotic. The pencil is passed over the 
surface to be acted upon, generally exuberant granulations. 
Better than this molded stick is a bead of fused silver nitrate 
on a wooden applicator or probe. This insures the use of the 
same applicator but once. 

Copper Sulphate. — Sulphate of copper (Blue Vitriol) occurs 
as blue transparent crystals or powder. It has a metallic, 
nauseating, astringent taste, and is soluble in water. It is 
largely used as a emetic in a dose of 0.25 to 0.50 Gm. (4 to 
7JH2 grains). The dose should not be repeated, and if vomiting 
is not quickly caused, the stomach should be washed out, lest it 
cause cauterization. 

As a caustic, copper sulphate is generally used in fused 
crystals as the blue stick, which is rubbed over the part to be 
treated. It is most frequently used on granular eye-lids. 

Potassium Hydroxide. — Caustic potash occurs in dry white 
masses, or as molded pencils, and is very soluble in water. It 
should not be handled with the bare ringers, as its escharotic 
action is very rapid. It is not much used as an escharotic, as 
its action is more difficult to limit than that of other escharotics. 
It may, however, be used to remove superfluous epidermis, for 
which purpose a 5 to 10 per cent, solution is employed. 



140 THE PRINCIPLES OF THERAPEUTICS 

Sodium Hydroxide (Caustic Soda) acts similarly to potassium 
hydroxide, but caustic potash is preferable. 

Zinc Chloride. — Chloride of zinc occurs as a white granular 
powder or in molded pencils, and is very soluble in water. It 
has been used to destroy growths. As its action in concentrated 
preparations is very painful and protracted, its use is rarely 
justifiable. 

Carbon Dioxide Snow. — Liquid carbon dioxide comes in 
steel cylinders, and when the stop-cock is opened the spray 
developes a snow of — 85 F. A mold of this carbon dioxide snow 
may be made, as Hare suggests, by holding a piece of thick 
chamois skin over the nozzle of the cock, and the snow forming 
in the pocket may be molded to any size desired. The chamois 
protects the hand from the intense effect of the cold. Hare 
states that when this molded snow is held on the tissues for 
ten to thirty seconds it acts as a stimulant, and from thirty 
seconds to a minute acts as an escharotic. The tissue to 
which it has been applied is frozen white. In a minute or two 
after the carbon dioxide snow has been removed the area 
becomes red and swollen and vesicles or blebs occur, similar to 
blistering. Several days later exfoliation takes place, a scab 
may form, and there may be a slight scar. 

This freezing substance has been used by dermatologists to 
destroy different kinds of growths or blemmishes on the skin. 
Too large an area should not be treated at once. 

CLASS III 
Drugs Used for Action on Mucous Membranes 

The drugs and preparations of this class coat and soothe 
inflamed mucous membranes, and also mechanically prevent 
harm from irritant substances which pass over them. Some 
drugs of this class are astringent and retard the normal secretion 
of the membranes and diminish excessive secretion. On 
account of the mechanical and astringent activities, when 
these preparations are swallowed, the digestive fluids of the 
stomach and intestines are more or less retarded in their output 
and digestion is slowed. 



ASTRINGENTS 141 

Inflamed mucous membranes require soothing treatment. 
Also to prevent irritation of the mucous membranes of the 
gastrointestinal tract, irritant drugs are generally administered 
combined with some protective preparation. On the other 
hand, too long use of even an inert mineral oil for laxative 
purposes can so continuously coat the intestinal walls as to 
inhibit normal secretion. Too much washing, scrubbing, 
gargling, hot water drinking before meals, constant taking of 
slushy, mushy, non-stimulating foods, and long repeated rectal 
injections and vaginal douching can but make the mucous 
membrane of the part abnormal and inhibit its normal secre- 
tion. Consequently, however useful and beneficial for an acute 
inflammation of a mucous membrane a local application or 
treatment may be, such treatment long continued is inadvisable, 
as it is likely to do harm, perhaps permanently. 

DEMULCENTS 

The drugs and preparations used to soothe mucous mem- 
branes are called demulcents. Besides those named under the 
classification of drugs, the following are also useful: Acacia 
(Gum Arabic) ; Althea (Marshmallow) ; Chondrus (Irish Moss) ; 
Glycyrrhiza (Licorice) ; and Tragacanth. 

ASTRINGENTS 

Drugs used to inhibit secretion are termed astringents be- 
cause they dry up secretions and are sufficiently irritant to 
cause a contraction of the tissue to which they are applied. 
This action of astringency can occur only on moist surfaces, 
whether external or internal, but these drugs are mostly used 
for action on mucous membranes. Astringents vary in the 
intensity of their action, from the mildest soothing astringency, 
which will hardly irritate sufficiently for an outpouring of white 
corpuscles, to a greater astringency that will cause irritation of 
a part, to a still greater astringency that will cause such chemi- 
cal reaction as will produce inflammation and local eschars, to 
such severe action as will cause actual corrosive ulceration and 
destruction of tissue. Many of the metallic poisonous drugs 
come under this class of irritant astringent drugs. 



142 THE PRINCIPLES OF THERAPEUTICS 

The most astringent metals in the order of their astringency 
are: lead, iron, aluminum, copper, zinc, and silver. Nitrates 
and chlorides of metals are more irritant and corrosive than are 
the acetates, citrates, and tartrates. The sulphates are less 
irritant than the last named salts. Most of these metallic 
preparations are primarily styptic, namely, causing sufficient 
coagulation of albumin to stop hemorrhage from small vessels. 
The more poisonous of these preparations, i.e., the more irritant 
ones, soon cause further destruction of the albuminate formed, 
corrosion and more hemorrhage. 

The symptoms of corrosive poisoning are described under the 
section on poisoning, Part XI, and therefore need not be describ- 
ed here. 

The indications for the use of astringents are local, namely, 
for some disturbance of the skin or mucous membrane. Conse- 
quently they are used to treat some part of the gastrointestinal 
tract, the upper air passages, the conjunctivae, the urethra, 
bladder, vagina, and rectum; or they are used for some localized 
or general disturbance on the surface of the body, as in certain 
inflammations, or ulcerations, of the skin. 

Before deciding that an astringent is needed, it should be 
remembered that a mucous membrane is relieved of its conges- 
tion by free secretion; hence many times anything that promotes 
free secretion or excretion relieves this congestion. As a dry 
mucous membrane is generally an irritated one, it may require 
soothing, moist applications, as frequently best offered by a 
physiologic saline solution. In other words, astringents are 
often misused. On the other hand, a mucous membrane may 
have become flabby and relaxed and have its circulation im- 
paired, and may need a slight local irritation as offered by some 
mild astringent. However, in such conditions circulatory 
stimulation and improved general nutrition will often correct 
the local mucous membrane mistake. 

The main objects of astringent action are to diminish secre- 
tion; to stimulate a membrane to a more healthy secretion; and 
to stimulate healing of some part of the skin or mucous mem- 
brane. Mild astringents and weak preparations of strong as- 
tringents are used for the first indication, and strong astringents 



ASTRINGENTS 143 

or stronger preparations are used to meet the last indication, this 
provided the application can be locally applied and its action 
terminates with the cessation of the application. Bismuth 
preparations and some preparations of tannic acid are generally 
the only astringents that should be used for the treatment of 
the stomach and intestines. The best preparation of bismuth 
for action in the intestinal canal is the subcarbonate. Some 
protein combination of tannic acid may also be used, especially 
for astringent action in the intestine. No other so-called as- 
tringent drug should be taken internally. There is absolutely 
no justification for taking nitrate of silver, or any other form 
of silver for that matter, into the stomach. Solutions of organic 
silver salts have strong germicidal activity, and are used for 
stimulant action in weak solutions on various external parts of 
the body, but though weak silver solutions may lessen secre- 
tions, they do not soothe the membrane. 

A valuable astringent wash is Liquor Alumini Subacetatis 
(Burow's Solution). It is soothingly astringent to the skin in 
the strength of from i part to 8 of water to i part to 15 of water 
This preparation is distinct from the Liquor Alumini Acetatis 
N. F., and is an improvement on that preparation. 

Some drugs are strongly astringent and yet not irritant, 
hence are used to stop local capillary bleeding. Such drugs are 
termed styptics. As styptics, tannic acid, the persalts of iron, 
peroxide of hydrogen solutions, and suprarenal solutions may 
be used. 

Preparations of copper, silver, and zinc salts are always 
stimulating, more or less germicidal, and in strong preparations, 
escharotic. The object of stimulating a mucous membrane is 
to cause a healthy reaction so that the tendency to return to 
health will be promoted. The object of stimulating a sluggish 
ulcer or sinus is to cause such a reaction as to promote the nor- 
mal tendency to heal. 

Tannic Acid. — Administration. — Tannic acid is obtained from 
nutgalls, and occurs as a yellowish amorphous powder or as 
spongy masses, its taste is astringent and disagreeable, and it is 
soluble in water, glycerin and alcohol. Tannic acid is often 
used as an antidote in poisoning by metals and alkaloids, with 



144 THE PRINCIPLES OF THERAPEUTICS 

which it forms tannates. These tannates are more or less in- 
soluble, but if they remain long in the intestine they may, in 
part at least, re-dissolve and allow poisoning to occur. Con- 
sequently, when tannic acid is used as an antidote, the stomach 
and intestines should later be thoroughly emptied. 

There is little use for tannic acid as such internally. If the 
astringent action of tannin is desired, it is better offered by one 
of the several protein combinations. Tannic acid is a mild 
irritant to the stomach and readily causes vomiting. When 
administered for action in the intestine, it should be given in 
capsules or one of the protein preparations may be used. The 
dose is 0.30 to 0.50 Gm. (5 to 73^ grains), given three, four, or 
more times a day, as desired. 

Tannic acid is frequently used as a wash or gargle to cause an 
astringent action in the mouth and throat. It should be ordered 
in a 1 Yz to 2 per cent, solution in 5 per cent, glycerin in water, 
or as a glycerite dissolved in water. Or it may be well to disguise 
the taste with peppermint or wintergreen water. The follow- 
ing prescription is a suggestion : 

f Tannic acid 4 Gm. 

Glycerin 10 mils 

Peppermint water up to 200 mils 

Mix. 
Sign : Dilute with an equal part of warm water and use as a gargle three times 
a day. 

Tannic acid is not a good treatment for an acute sore throat; 
it is better for relaxed and flabby conditions of the throat. 

Externally solutions of tannic acid in water are sometimes 
applied to harden the skin, as to the nipples before nursing, and 
to dry up secretion, as sweating axillae, but other preparations 
are better. It is, however, harmless. 

The official preparations are : 

Glyceritum Acidi Tannici is a preparation of glycerin contain- 
ing 20 per cent, of tannin. It may be used in making tannic 
acid solutions, or it may be applied by cotton applicators to 
inflamed parts of the mouth and throat. 

Trochisci Acidi Tannici are troches (each of which contains 
0.06 Gm. of tannin) used for solution in the mouth. 



ASTRINGENTS 145 

Unguentum Acidi Tannici is an ointment containing 20 per 
cent, of tannin. 

Action. — The only action of tannic acid externally on the 
skin is to cause a drying of normal secretions and a coagulation 
of albuminous abnormal secretions, and hence to inhibit exu- 
dation. On mucous membranes it coagulates the albumin and 
causes sufficient irritation to more or less constrict the tissues 
and dry the surface. Tannic acid will more or less constrict 
the small vessels of the membrane to which it is applied, 
and it is sufficiently styptic to stop oozing from small blood- 
vessels. It will not ordinarily stop hemorrhage from the 
larger vessels unless other methods are first used. 

Tannic acid slows digestion and more or less forms tannates 
with the proteins of the food. It generally causes constipa- 
tion, but if large amounts of tannic acid are taken it may cause 
diarrhea. If there is iron in the food, or iron has been ad- 
ministered as a medicine, tannic acid will cause the formation 
of black tannates as an ink. A small portion of tannic acid is 
absorbed as sodium gallate, but there is no systemic action of 
any importance from tannic acid or its preparations, although 
both tannic acid and gallic acid have been given in albuminuria, 
and in bleeding from the kidneys. At times gallic acid has 
seemed to be of benefit in bleeding from the kidneys. 

There is no over-action or toxic action from tannic acid, al- 
though as stated, it may cause vomiting, and in larger doses 
an increased activity of the bowels. 

Uses. — The principal uses of tannic acid have already been 
described. Combinations of tannic acid in powders, ointments, 
or solutions are sometimes used in the mouth, nose, and rectum, 
and on irritated regions of the skin, and for some skin diseases. 
Other preparations, at the present time, are more used for these 
purposes. 

Prolan, N.N.R. is a combination of tannic acid and casein 
containing about 50 per cent, of tannic acid. 

Acetannin, N.N.R. is an acetic acid ester of tannin. Tanni- 
gen is a similar preparation. 

Both of these preparations are used at times with advantage 
in persistent diarrhea, and for treatment of ulcerations of the 
10 



146 THE PRINCIPLES OF THERAPEUTICS 

intestines. They are not much dissolved in the stomach, are 
non-irritant to the stomach, and, therefore, are satisfactory 
methods of administering tannic acid for intestinal conditions. 

The dose of the Protan is about 0.50 Gm., best in capsule, 
every three or four hours. The dose of the Tannigen is about 
0.25 Gm. best in capsule, every three or four hours. 

Silver Nitrate. — Administration. — Silver nitrate occurs as 
colorless, transparent crystals, which are very soluble in water. 
Solutions should always be made with distilled water, as any 
organic matter changes the color of the solution to gray, or even 
black, and exposure to light does the same; hence solutions are 
best kept in colored bottles with glass stoppers. 

There is no excuse for using silver nitrate internally for 
systemic treatment. It may be used in weak solutions in the 
treatment of chronic inflammations of the bladder, rectum, and 
lower colon. These silver solutions must be immediately passed 
out of the body, or, if they are not expelled, a sodium chloride 
solution should be injected to cause an insoluble chloride of 
silver to be formed. 

Silver nitrate has been used in the treatment of gastric ulcer, 
but on account of the danger of too much absorption it is hardly 
justifiable, also it is problematical whether the solution, or a 
dissolving capsule, will hit the spot to which it is directed. 
Acute metallic poisoning, with nephritis, may occur, and chronic 
metallic poisoning has not infrequently occurred, from the use of 
silver nitrate internally. Therefore, the only justifiable use for 
nitrate of silver is locally, i.e., externally, or in cavities of the 
body that can be quickly evacuated. 

Action. — Silver nitrate is a powerful germicide, forming a 
silver albuminate with protein matter and setting free a small 
amount of nitric acid. On account of the formation of the 
albuminate the destructive action is not deep. Metallic silver 
inhibits germ growth and silver foil is often used as a germicide 
and a protective to healing surfaces. 

The eschar produced by the action of silver nitrate is white, 
later turning black. When solutions stain the skin it may be 
removed, if treated soon, with a saturated solution of potassium 
iodide, but, if it is not soon treated, the stain will remain until 



ASTRINGENTS 



147 



exfoliation of the epidermis occurs. Nitrate of silver stimulates 
the healing of a sluggish ulcer, provided it is not used too fre- 
quently or too many times. It has been thought that it could 
over-stimulate a part and cause tumor growth. When nitrate 
of silver is absorbed it may cause, after two or three weeks' 
treatment, deposits of organic silver in the skin and mucous 
membranes, and perhaps in the organs. The mucous mem- 
branes show brown spots, and the skin shows blue patches, or 
even a generalization of bluish pigmentation. Such pigmenta- 
tion will always remain, and can never be removed. This con- 
dition has been termed argyrism or argyria. As stated, such 
chronic poisoning should never occur, as there is no excuse for 
administering nitrate of silver internally. 

Toxic Action. — Acute poisoning is similar to that of other 
gastro-intestinal irritants, with lowering of the blood-pressure, 
weakening of. the heart, and irritation of the nervous system, as 
shown by convulsions, and later coma and collapse. 

Treatment of Acute Poisoning. — The antidote is a strong 
solution of sodium chloride administered immediately. If 
vomiting does not soon occur the stomach should be washed 
out. The later treatment is that of the local inflammation that 
has been caused. 

Uses. — Silver foil is often used as a surgical dressing, both for 
protective and antiseptic purposes; it also tends to prevent ex- 
uberant granulations. The stick nitrate of silver (Lunar Caustic, 
Argenti Nitras Fusus,) is often used as an escharotic, as well as 
is a fused bead of nitrate of silver on a wooden applicator. The 
latter is better, because it can be destroyed after it is once used. 
Twenty-five per cent, nitrate of silver solutions are generally as 
valuable, applied by means of a swab. Weak solutions have 
been used on the mucous membrane of the nose, nasopharynx, 
bladder, urethra, vagina, and rectum. Nitrate of silver appli- 
cations are very curative treatment for cankers in the mouth. 
However, for most purposes organic silver salts are now more 
used than is the nitrate of silver. 

Except in the prevention of ophthalmia neonatorum, by in- 
stillation into each eye of the newly born child of two drops 
of a 1 per cent, watery solution of nitrate of silver, known as 



I48 THE PRINCIPLES OF THERAPEUTICS 

Crede's method, organic preparations of silver are now the ones 
used in all inflammations of the eyes. 

Nitrate of silver is now rarely used in preventing gonorrhea. 
Other silver solutions or weak corrosive sublimate solutions are 
more used. To destroy tissue, except to remove exuberant 
granulations or to stimulate the base of an ulcer, other escha- 
rotics are used more than nitrate of silver. To destroy warts, 
callous skin, etc., nitrate of silver is now rarely used. 

The book New and Nonofhcial Remedies, edition of 1920 
recognizes the following silver preparations: 

Cargentos, sl colloidal silver oxide, containing about 25 per 
cent, of silver. 

Collargol, an allotropic form of metallic silver, containing a 
small percentage of albumin and about 78 per cent, of silver. 

Argyrol, sl compound of a derived protein and silver oxide, 
containing from 20 to 25 per cent, of silver. 

Solargentum-Squibb, a compound of silver and gelatine, con- 
taining about 20 per cent, of silver. 

Sophol, a compound of silver and methylenenucleinic acid. 

Protargol, a compound of albumin and silver, containing 
about 8 per cent, of silver. 

Proganol, a compound of albumose and silver, containing a 
little more than 8 per cent, of silver. 

Of these preparations the most used are Cargentos, Collargol, 
Argyrol and Protargol. Argyrol is the one generally preferred, 
and is used in solutions of various strength, from 10 to 25 per 
cent. The value of these solutions in the prevention of and in 
curing many localized infections is very great. 



CLASS IV 

Drugs Used for Local Action in the Stomach 

drugs used to increase the appetite 

Drugs administered to increase the appetite are generally 
bitter, but it is a mistake to believe that every loss of appetite 
should be combated by one of these drugs, as many times the 



TO INCREASE THE APPETITE 1 49 

anorexia is due to inflammation of the gastric mucous mem- 
brane. If there is much inflammation, i.e., if gastritis is 
present, even in a mild form, bitter tonics are not indicated to 
increase the appetite and will often defeat the object for which 
they are administered, even producing nausea. Bitters should 
also not be used when there is hyperacidity of the stomach, as 
they tend to increase that condition. If gastritis is present it 
should be treated with bismuth and soda, or with some other 
sedative, and by such an arrangement of the diet as will dimin- 
ish or prevent indigestion. When gastritis or simple indigestion 
improves, the appetite will return. 

If the loss of appetite is due to an anemic condition of the 
stomach and gastritis is not present, any mild irritant to 
the mucous membrane of the stomach will often increase the 
appetite, and the best stimulant is a weak bitter. The bitter 
should not be too strong, and many times it is well to have it 
combined with aromatics, as aromatics and aromatic oils also 
stimulate the stomach and hence the appetite. 

Many drugs increase the appetite by improving the systemic 
condition, but the best bitter appetizers are cinchona, gentian, 
and nux vomica. If a capsule or pill of quinine is taken some 
hours before a meal (and quinine is generally given as a tonic 
three times a day, after meals) it causes an increase of appetite 
by giving a bitter taste, owing to a slight excretion of the 
quinine with the saliva, and the patient desires more food. 
However, the official Tincture of Cinchona in teaspoonful doses 
in a wineglass of water before meals, or an Elixir of Calisaya in 
dessertspoonful doses before meals are efficient methods of 
increasing the appetite. If a simple clean bitter is desired, the 
Tincture of Nux Vomica in from one to five drop doses in a 
wineglass of water before meals is also very efficient. The 
official Compound Tincture of Gentian in teaspoonful doses, 
in water, before meals is also a valuable stomachic. 

If the digestion seems to be impaired, as evidenced by 
gastric flatulence and a coated tongue, 5 to 10 drops of Acidum- 
Hydrochloricum Dilutum, taken in a wineglass of water directly 
after meals, not only aids digestion, but seems to promote the 
appetite for the next meal. 



150 • THE PRINCIPLES OF THERAPEUTICS 

If the patient is anemic, iron in most any form will increase 
the appetite. It is best given in some simple form directly 
after meals. 

There are various other bitter, non-poisonous drugs that are 
official, but they are superfluous, as the above preparations are 
sufficient. 

DIGESTANTS 

Indigestion is a very frequent condition, especially in the 
United States, largely due to rapid eating, eating too rich 
foods, drinking too many sweet, so-called "soft drinks," drink- 
ing too much ice water, eating between meals, and to the 
over-use of coffee, tea and tobacco, to say nothing of the fre- 
quency of indigestion due to some general systemic disturbance. 
Indigestion is frequently due to constipation, and also, many 
times, to the bad habit of taking too strong laxatives. Con- 
siderable stomach indigestion is caused reflexly by disturbances 
of the nervous system, the most frequent of which is eye- 
strain. 

The larger part of indigestion is gastric in origin, and the 
principal symptoms are distress, gastric flatulence, pyrosis, and 
heartburn. Pain, nausea and vomiting are rare symptoms in 
simple dyspepsia. When these symptoms occur, there is an 
acute indigestion or gastritis, or there is some more serious 
cause. 

The treatment of gastric indigestion is suggested by the above 
list of causes. A correction of the diet and the method of 
eating will often cure the condition. To treat dyspepsia by 
the administration of digestants, one must bear in mind the 
physiology of digestion. The diastase from the saliva, or a 
diastase that may be given a patient, will act on the carbo- 
hydrates in the stomach until free hydrochloric acid or a 
considerable amount of acid peptones from the peptic digestion 
have developed, which ordinarily will be from one to one and a 
half hours after the food has been taken. The acid peptic 
digestion then proceeds from three to four hours, until the 
stomach is emptied, gradually, into the duodenum, where 
the digestion again proceeds in medium rendered alkaline by the 



DIGESTANTS 



151 



bile. Obviously, then, it would be a mistake to administer 
hydrochloric acid or pepsin before the meal, and it would also 
be a mistake to give an alkali two hours after a meal. As a 
matter of fact, the pepsin of the stomach is rarely deficient, 
except in certain cases of pathologic conditions of the mucous 
membrane. The hydrochloric acid is often deficient. There- 
fore, many times indigestion will be quickly corrected by a 
proper arrangement of the diet and the administration of 5 or 
10 drops of dilute hydrochloric acid, in water, after meals. 
Also an aid to digestion is a moderate amount of water, taken, 
not too cold, in the latter part of a meal or after a meal. 

Unless the starchy food has been greatly diminished, sodium 
bicarbonate in 0.50 to 1 gram dose, combined with 0.50 to 1 
gram of bismuth subcarbonate, taken three times a day, before 
meals, will also often aid digestion. The bismuth soothes 
a possibly irritated mucous membrane, and the bicarbonate of 
sodium prolongs the starch digestion. 

Some of the so-called "hyperacidity" and pyrosis occurs be- 
cause food remains too long in the stomach, from lack of motil- 
ity of the stomach or from some other reason, and is due to the 
formation of lactic acid and is not due to an excess of hydro- 
chloric acid. The administration of dilute hydrochloric acid 
in these cases corrects the condition by hastening the comple- 
tion of normal digestion and apparently hastens the passage of 
the food into the duodenum. In these cases a glass or two of 
water drunk three or four hours after a meal is of benefit. If 
the hydrochloric acid increases the sensation of burning and 
acidity, it should, of course, be stopped. 

As stated, unless there is some serious disease of the stomach, 
as atrophy of the gastric mucous membrane or cancer, pepsin 
is rarely needed, but in these conditions pepsin, in good sized 
doses, may be given in any pleasant manner. 

While pancreatin will digest protein in neutral, as well as 
partially, perhaps, in faintly acid, medium its greatest activity 
is in alkaline medium. It has lately been disputed whether or 
not it is destroyed by passing through the stomach, namely, 
through the acid digestion, before it reaches the duodenum 
where it is normally active. It seems entirely unnecessary to 



I52 THE PRINCIPLES OF THERAPEUTICS 

spend any time discussing this subject, as it is not necessary to 

give pancreatin as a digestant. To pre-digest food pancreatin 

is very valuable, and for this activity it is combined with a small 

amount of sodium bicarbonate. 

A brief description of the drugs of this class will be found 

under their titles in Part II, the section of the United States 

Pharmacopoeia. 

ANTACIDS 

Treatment by drugs for this purpose is purely symptomatic 
treatment. Alkalies should not be used too long or too fre- 
quently, as they not only antagonize hyperacidity, but may 
cause irritation of the stomach by constantly stimulating the 
antagonistic action of the acid -secreting glands. As stated 
above, an alkali before meals may prolong the diastatic action 
of the saliva on starches, but if given some time after meals, 
will interfere with gastric protein digestion. 

It is better, by diet and proper management, to prevent 
hyperacidity rather than to treat it, and the treatment 
of heartburn, pyrosis, and distress from hyperacidity is 
symptomatic, and many of the symptoms of hyperacidity are 
due to lactic acid. Too much hydrochloric acid may be secreted 
in nervous irritability and in mental tire and reflexly from some 
abdominal disturbance, or it may be due to some increased irri- 
tability of the stomach mucous membrane. Butter, bland oils, 
and arrangement of the diet may control the condition. 
Atropine so much used for hyperacidity generally fails to help 
this condition. 

The drug most frequently used to combat gastric acidity is 
sodium bicarbonate, given either alone or combined with bis- 
muth, or with peppermint, charcoal, or pepsin, and at times with 
ginger. The value of all of these so-called digestive tablets or 
powders lies principally in the bicarbonate of sodium. An 
effective dose of sodium bicarbonate is 0.50 to 1 Gm., repeated 
in fifteen minutes or half an hour, if needed, taken with plenty 
of water, and most efficacious in hot water. If there is much 
gas, causing distress, the official Spiritus Ammonia, Aromaticus 
in half a teaspoonful dose, taken well diluted, is an efficient rem- 
edy. This may be repeated in half an hour, if needed. 



TO RELIEVE IRRITATION IN STOMACH 1 53 

A more sedative antacid for the stomach is magnesia, and the 
best preparation is a milk of magnesia, given in warm water in 
1, 2, or 3 teaspoonful doses. It may be repeated in an hour, if 
needed. Magnesia has slight laxative properites. 

Magnesium oxide may also be used as a mild antacid. Cal- 
cium is also used as prepared chalk (Creta Prceparata) , as the 
precipitated calcium carbonate (CalciiCarbonas Prcecipitatus) , 
or as the official lime water (Liquor Calcis) . These drugs and 
preparations are described in Part II, under the section on the 
United States Pharmacopoeia. 

DRUGS USED TO RELIEVE IRRITATION IN THE STOMACH 

Irritation or inflammation of the stomach mucous membrane 
is the same as irritation or inflammation of any mucous mem- 
brane, and requires to be soothed in the same way. The food 
must be bland, if it is not temporarily prohibited, plenty of 
water must be taken, and many times demulcent drinks, as 
albumin water, flaxseed or slippery elm tea, or some other 
bland drink. When properly prepared and in good condition, 
milk of magnesia given with warm water is one of the most 
soothing preparations. 

The drugs most frequently used to relieve gastric irritation 
are the bismuth preparations, and of these the best is the sub- 
carbonate. Sometimes the subgallate with its slightly greater 
astringency is the salt of preference. The subnitrate of 
bismuth is the salt that has been and is still used the most. 
In certain conditions of the stomach and intestines, such as a 
fresh ulcerated absorbing surface, this salt may cause poisoning. 
The subcarbonate cannot cause such poisoning. 

There is no good reason why silver nitrate should ever be 
given internally, although it has been used frequently in chronic 
inflammation and ulceration of the stomach. It may do harm. 

Suprarenal preparations have been used to prevent or inhibit 
hemorrhage from the stomach. Tannic acid has been used for 
stomach conditions, but it is more or less nauseating and slightly 
irritant . The non-irritant protein combinations of tannic acid 
do not develop tannic acid action until they have reached the 
intestines. 



154 



THE PRINCIPLES OF THERAPEUTICS 



Bismuth Subcarbonate.— Administration. — The subcarbonate 
of bismuth occurs as a yellowish white powder, insoluble in 
alcohol and water. For action in the stomach it is best admin- 
istered in powder in a dose of 0.50 to 2 Gm. It may, or may 
not, be combined with bicarbonate of sodium, but many times 
the sedative action in the stomach is better when so combined, as 
1 Gm. of subcarbonate of bismuth and 0.50 Gm. of bicarbonate 
of sodium, taken three times a day, just before meals. If it is 
very disagreeable for the patient to take a powder as such, the 
bismuth salt may be given in a small glass of vichy or other 
sparkling water; the bubbles suspend the heavy salt and the 
whole may be drunk as a liquid. 

If it is desired that the stomach should be well coated with 
bismuth for sedative and astringent purposes, as perhaps in 
ulcer, the best method is to give a large dose, at least 2 Gm. 
(30 grains) at one dose, before breakfast, preceded half an 
hour by a cup of hot water. 

For action on the intestines, as for acute diarrhea, a gram of 
the subcarbonate of bismuth may be given every two hours for 
ten doses, best combined with phenyl salicylate (salol) in 0.30 
Gm. (5 grain) doses. For astringent action for a chronic 
condition in the bowels, bismuth subcarbonate may be given in 
capsules of 0.30 to 0.50 Gm., or in 5 or 10 grain tablets every 
three or four hours for some days. Bismuth should not be 
given too long, as it tends to cause constipation and the forma- 
tion of hardened masses of feces in the intestines. 

Action. — Bismuth subcarbonate has no action on the skin 
except that of a dry protective powder; on ulcerated surfaces it 
has a slightly astringent action. Bismuth powder should not 
be used on a fresh raw surface, whether an acute burn, a blister, 
or a denuded surface from an injury, as absorption and metallic 
poisoning may occur. 

The action of bismuth throughout the alimentary tract is a 
local one. It is soothing and mildly astringent. In the large 
intestine sulphide of bismuth is formed which causes the stool to 
become black and the feces to have more or less of a sulphurous 
odor. 

It is doubtful if bismuth subcarbonate can cause poisoning. 



TO RELIEVE IRRITATION IN STOMACH 1 55 

The subnitrate has, rarely, caused poisoning, sometimes serious, 
(possibly sometimes contaminated with arsenic) due to the 
formation of nitric acid and nitrites. The symptoms have been 
inflammation of the duodenum, liver, and kidneys. When 
bismuth salts have been absorbed from fresh wounds the 
symptoms are those of a metallic poison, not dissimilar to 
mercurial poisoning; the treatment is the same as that for 
other metallic poisons. 

Uses. — The principal use of subcarbonate of bismuth is in 
gastric and intestinal irritations and inflammations. It is of 
little value in inflammation of the lower part of the small 
intestine or of the large intestine. It is of value in ulceration of 
the large intestine when given by colon injections. 

Bismuthi Subnitras. — Subnitrate of bismuth occurs as a 
heavy white powder insoluble in alcohol and water. It has been 
used much more frequently than the subcarbonate of bismuth 
and for the same purposes, and in the same doses. The action 
is the same, with the exception, as above stated, that the sub- 
carbonate is a safer preparation to use. 

Bismuthi Subgallas. — The subgallate of bismuth ("Derma- 
tol") occurs as a bright yellow powder, and is insoluble in water 
and alcohol. This preparation has been used externally as a 
drying powder more frequently than the other forms of bismuth, 
especially on moist eczemas, and for sweating axillae and feet. 
It is a finer, lighter powder than the other salts of bismuth. Its 
best action internally is in chronic intestinal disturbances, and 
is best given in capsules containing 0.30 to 0.50 Gm. (5 to 7V2 
grains), three or four times a day. The action is similar to that 
of the subcarbonate. 

Bismuthi Betanaphtholas. — Bismuth betanaphthol ("Or- 
phol") is a compound of bismuth and betanaphthol, containing 
not less than 15 per cent, of betanaphthol. This preparation 
occurs as a yellowish or grayish-brown powder which is insolu- 
ble in water and alcohol. In the intestines the naphthol is re- 
leased from this salt and causes more or less antiseptic action. 
It has been used as an astringent antiseptic in diarrhea, best 
given in capsules, in doses of from 0.30 to 0.50 Gm. (5 to 7^ 
grains); but the combination of bismuth subcarbonate and 



156 THE PRINCIPLES OF THERAPEUTICS 

phenyl salicylate, as above suggested, is better in diarrheal 
conditions. 

Bismuthi Tribromphenas, N.N.R. — Bismuth Tribromphe- 
nate (Xeroform) is an amorphous, yellow, tasteless powder, 
which is very slightly soluble in water. It is recommended for 
use externally in the place of iodoform as being non-irritant and 
having mild antiseptic properties. 

Other official preparations of bismuth are not needed. 

Barium Sulphate, N.N.R. — This preparation has largely 
superceded bismuth subnitrate and bismuth subcarbonate in 
roentgen-ray examinations of the stomach and intestines. 
About 2 ounces of barium sulphate are administered, mixed with 
some cereal gruel. There is no medicinal use for barium. The 
preparation in this dose seems non-poisonous. 

EMETICS 

The irritant emetic drugs in the order of their activity are: 
mustard, ipecac, zinc sulphate, copper sulphate. The sim- 
plest of these, namely, mustard, may be given in a dose of a 
tablespoonful or more, stirred in a glass of warm water. The 
emetic dose of powered ipecac is 2 Gm. (30 grains), also given 
stirred in a glass of water; or the syrup of ipecac may be 
given in 1, 2, or 3 teaspoonful doses, and repeated in ten or 
fifteen minutes, if vomiting has not been caused. The emetic 
dose of zinc sulphate is 2 Gm. dissolved in half a glass of water, 
not to be repeated. If vomiting does not occur within ten or 
fifteen minutes, the stomach should be washed out. 

A good combination to be carried in the emergency bag is: 1 
Gm. of zinc sulphate and 2 Gm. of powdered ipecac, a powder 
to be administered at once, and repeated in fifteen minutes, 
if vomiting has not been caused. 

Copper sulphate is the most active of these irritant emetics, 
and the dose should be 0.50 Gm. (7^ grains) dissolved in warm 
water, given at once. If vomiting does not occur in five or ten 
minutes, the stomach should be washed out. 

The emetic drug that acts on the vomiting center, when 
administered hypodermatically is apomorphine. 



CARMINATIVES 



157 



Apomorphine Hydrochloride. — A dministration . — Apomor- 
phine is an alkaloid prepared from morphine by the abstraction 
of one molecule of water; the hydrochloride is the official pre- 
paration. This salt occurs as minute white or greenish-white 
prisms, which soon become green, and the solutions become green, 
on exposure to light and air. It is not very soluble in water. 

There is no good use for this drug except as an emetic, and 
as such it should always be given hypodermatically. The 
hypodermatic dose is 0.005 to 0.006 Gm. (}{ 2 to Mo grain). 

Action. — When given hypodermatically vomiting occurs 
within a few minutes, unless some narcotic poison has been 
taken, when it may take longer for its action. The vomiting is 
caused by direct action on the vomiting center in the medulla. 
The emetic dose rarely requires to be repeated, but if nausea 
persists or vomiting is frequent, prostration is caused and some- 
times collapse. For this reason, as soon as the stomach has 
been thoroughly emptied, stimulants, best atropine and caffeine, 
should be given. Of course in poisoning that necessitated the 
use of apomorphine, the particular poisoning must be treated, 
but if the poison was a depressant, apomorphine must be used 
with care. 

Uses. — Although apomorphine has been recommended as an 
expectorant, to be used to promote secretion of the air passages, 
it is not good treatment, as it is too depressant. There is no 
real good reason for administering apomorphine for any purpose 
except to cause vomiting, and then it should be given hypoder- 
matically or intramuscularly. It may be used to produce 
vomiting in such conditions as when there is intense gastric 
pain from contractions of the stomach with the cardia and 
pylorus closed. Apomorphine will almost instantly relax the 
spasm of these sphincters, especially of the cardia. 

CLASS V 

Drugs Used for Local Action in the Intestinal Canal 

carminatives 

All spices, preparations of spices and aromatic oils increase 
peristalsis and hence have carminative action. Of the spices, 
capsicum, ginger,and peppermint are the best, while asafetida 



I5S THE PRINCIPLES OF THERAPEUTICS 

(a garlic) is also a promotor of peristalsis. Onions act as car- 
minatives, hence onion broth is as efficient as asafetida pills. 
Anise is often given to babies for intestinal flatulence. 

Turpentine enemas are given to relieve intestinal distention, 
and cold to the abdomen promotes peristalsis. Heat applica- 
tions to the abdomen in the form of stupes relieve localized 
abdominal congestion and may thus relieve spasm of some part 
of the intestines and promote peristalsis. Dry heat applications 
to the abdomen also relieve local congestion and spasm and 
hence promote normal peristalsis. 

Intramuscular injections of ergot are of value in intestinal 
paresis, and atropine, in large doses, is of benefit in intestinal 
spasm and colic by relieving a spastic condition of some part of 
the intestine and thus allowing normal peristalsis to occur. 
Pituitary extracts, given hypodermatically, also increase 
peristalsis. 

CATHARTICS 

These drugs are well sub-classed, for therapeutic purposes, 
into laxatives, purgatives, saline purgatives, and irritant 
purgatives. 

A laxative drug is one that may be used ordinarily for a long 
time without causing inflammation of the gastrointestinal tract 
or a tendency to a worse condition of constipation. 

A purgative is a drug that is used once (repeated if needed) 
to more or less rapidly evacuate the bowels. These drugs 
should not be used continuously, or be taken repeatedly, as 
they are likely to irritate the intestine; cause inflammation; 
cause too much depletion; and increase a tendency to consti- 
pation. 

The saline purgatives are mineral salts, which are very useful 
in causing rapid evacuation of the bowels. In certain condi- 
tions a small dose of one of these saline drugs, given before 
breakfast, may be good medication, as in over-weight, in pleth- 
ora, at times in insufficiency of the kidneys, and in high 
blood-pressure; but simply for the treatment of constipation 
saline purgatives should not be used. 

The irritant purgatives are those that cause very active, more 



CATHARTICS 1 59 

or less rapid movements of the bowels. If they are given in 
large or in repeated doses they are likely to cause inflammation, 
and very prostrating, if not poisonous effects. In other words, 
the drugs classed as irritant purgatives should not be used unless 
there is a positive indication for their use, such as systemic 
poisoning, or when some poisonous drug has been taken and 
very rapid evacuation of the bowels is necessary. 

Cathartic drugs and even the laxative drugs are used too 
much; the people of this country seem to be cathartic crazy. 
One has but to read the advertisements of nostrums in one of our 
second class daily papers to realize that the American world 
must think itself constipated. If these advertisements did not 
sell the nostrums they represent, the cost of the advertising 
could not be paid. 

Before discussing the indications for the use of cathartics, it 
is well to suggest when cathartics should not be used: (i) 
They should never be used habitually, even the laxatives, ex- 
cept by a small percentage of individuals. (2) Unless there is 
some special indication they should not be given as routine 
practice before operations. (3) Unless there is some special 
reason they should not be given too soon after an operation, or 
too soon after parturition. (4) They should not be given after 
a profuse diarrhea, although they should be given if the diarrhea 
has just begun. (5) They should not be given when there is 
acute abdominal pain, except possibly after a careful considera- 
tion of the diagnosis, when castor oil may be administered. (6) 
They should not be given in acute heart weakness. (7) They 
should not often be given in cardiac dropsy. (8) They should not 
be given in too large doses even in systemic poisoning. 

In the beginning of most acute infections it is generally ad- 
visable to unload the bowels with some purgative, and to greatly 
modify the diet. It is also advisable during illness, when the 
heart is in good condition and the patient is taking food, to have 
the bowels move at least every other day. Under these conditions 
they may require the aid of some simple laxative or of an enema. 
The simplest and most effective enema is an ounce of glycerin 
and an ounce of water. It may be well to have the bowels 
move every day during illness, when the glycerin enema may 



l6o THE PRINCIPLES OP THERAPEUTICS 

be given on one day and some simple laxative on the alternate 
day, if the bowels do not move without such treatment. If 
much fruit can be given, the bowels may move without help. 

It has been a mistake to purge every patient before operation. 
It is also a mistake to give such a patient either divided doses 
of calomel or a saline too soon after an operation, and divided 
doses of calomel are almost always a mistake. A single proper 
dose is much better. 

It is a mistake to cause purging in cardiac failure, in cardiac 
dropsy, and in cardiovascular-renal disease, as many a time the 
severe purging is the last straw to cause the patient to succumb. 

It is not proposed to discuss here the whole treatment of 
constipation, but except for a short time it is a mistake for 
most individuals to take laxatives. Constipation is best 
treated: (i) by the regular habit of going to stool at the same 
time every day, best after breakfast; (2) by diet; (3) by exer- 
cise; (4) by massage and exercise of the abdominal muscles. 

Constipation is a very common symptom of most diseases, and 
when the diagnosis is made and the general condition corrected 
the patient may have normal movements of the bowels. The 
frequency with which chronic abdominal disturbances cause 
constipation should also be recognized — whether gall-bladder 
disturbances, chronic appendicitis, ovarian disturbance, or 
some ulceration. The constipation then is purely a symptom. 

The habit of the individual must be considered in deciding 
whether it is best for him to have one or two movements of the 
bowels a day; ordinarily one should be sufficient. If, however, 
he has hemorrhoids, or a tendency to hemorrhoids or conges- 
tion in the pelvic region, it is well to have a movement of the 
bowels before going to bed, thus relieving unnecessary pelvic 
pressure. On the other hand, some individuals, generally 
women, are perfectly well and perfectly healthy and have good 
digestion though they have a movement of the bowels only on 
every second, and sometimes on every third day. Movements 
of the bowels every third day does not seem to be normal; but 
if every second day is the habit, and the patient is well, he 
should not be disturbed by cathartics. 

Some patients, especially those who cannot take much exer- 



LAXATIVES l6l 

cise, in spite of regularity of habits, and a regulated diet and 
an increased ingestion of water, do not have normal movements 
of the bowels without some little help. With such patients a 
small dose of cascara, of aloin or aloes, or of senna, taken daily, 
is probably of no more harm than the daily dose of tea or coffee, 
or for that matter, of pepper and spice or some other condiment. 

It is always advisable in constipation to tell most patients to 
drink more water. A glassful of water on going to bed, and 
another before breakfast is an aid in curing constipation. 
Fruit before breakfast, and, for those who tolerate it well, at 
bedtime, is good treatment. The value of bran foods should 
be urged. 

It is inadvisable to allow a patient to use enemas for any 
length of time, either of water, of soap and water, or of otherwise 
medicated water. The injections rarely reach the colon, and 
generally distend the rectum and possibly the sigmoid flexure, 
and soon the bowel acquires the habit of needing this distention 
before it will perform its duty. There is no harder simple 
habit to cure than the habit of taking enemas. Very much 
worse is the enema habit than is the habit of a small dose of a 
simple laxative. On the other hand, an enena is frequently 
indicated to unload the bowel, and colon washing is very essen- 
tial in certain conditions of the large intestine; but this should 
be considered medication for specific purposes, and injections 
of solutions into the bowel should not be used as routine practice. 

LAXATIVES 

Agar. — Agar often acts efficiently as a laxative because it, 
acquiring water, does not give it up, and causes the stool to be 
bulky and pultaceous, and gives the intestine moist matter 
upon which to contract. 

Aloes. — Aloes may be termed a tonic laxative, and is one of 
the best drugs for this purpose. It is slow to act, taking from 
eight to ten hours, or more, and therefore is best given directly 
after the evening meal or at bedtime. It should be taken with 
plenty of water, if the stomach is empty. Aloes may be admin- 
istered as the official pill of aloes, each pill containing 2 grains 
of the drug, or in the form of the official compound rhubarb pill 
11 



1 62 THE PRINCIPLES OF THERAPEUTICS 

which contains 2 grains of rhubarb and 1}^ grains of aloes. 
Aloes, however, is most frequently administered in the form of 
its active principles, aloin. As aloes is a stimulant to the mus- 
cular coat of the intestine, especially of the large intestine and 
may irritate the rectum, it is generally best not to use it when 
there are hemorrhoids, pregnancy, or congestion of the pelvic 
organs. 

As large doses may cause colicky pains, aloes does not make 
a good cathartic, but it makes a most valuable laxative, and 
one of the best combinations is a pill or tablet made of : 

Aloin 0.02 Gm. 

Sulphate of strychnine 0.0015 Gm. 

Powdered ipecac o . 03 Gm. 

Extract of belladonna o . 01 Gm. 

If this combination is administered daily for about two weeks, 
then two-thirds of the dose for another week, and half the dose 
for the following week, combined with proper diet and regularity 
in exercise, the constipation may be cured. At any rate, this, 
or some similar combination, has the advantage of not necessi- 
tating an increase of the dose. 

Ox-gall. — Bile is always more or less of a laxative, and when 
the secretion of the bile is insufficient or it is absent from the in- 
testines constipation occurs. As ox-gall contains excretives 
which are depressant and lower the blood-pressure, it should not 
be given for more than four or five days at a time. In other 
words, its use is limited, and its value is uncertain. 

The bile salts Sodium Glycocholate and Sodium Taurocholate 
are now sometimes used in insufficiency of the liver, but, like 
the preparations of the whole bile, they are depressant and 
should not be used for more than a week at one time. They 
may be somewhat stimulant to the secretion of the liver and 
may tend to lessen the formation of concretions in the gall- 
bladder. 

Glycyrrhiza. — Licorice is a mild laxative, and the official Com- 
pound Licorice Powder, in which senna plays the largest part 
with the sulphur a close second, is a very popular laxative. 
The combination contains 23 per cent, of glycyrrhiza, 18 per 



LAXATIVES 163 

cent, of senna, and 8 per cent, of washed sulphur. This prepa- 
ration should be more used as a purgative than as a laxative, 
i.e., intermittently rather than regularly. 

Magnesium Oxide. — Magnesia is a mild laxative, is harmless, 
and is well used in the form of milk of magnesia. 

Petroleum Oil. — Mineral oil is now the fad. It was at first 
thought that the Russian mineral oil was better than our mineral 
oil, but our purified oils are as valuable as any imported oil. 
The finer classes of these oils are tasteless, odorless, and color- 
less. They act purely mechanically, and cause action of the 
bowels by softening the feces and tending to promote their pro- 
pulsion to their exit. Large doses are generally required ; small 
doses are not very efficient. Too large doses, and with some 
individuals, small doses, cause a leakage of oil from the rectum, 
which is very unpleasant. For patients who have dry, hard 
feces, such treatment for a time is valuable, but to take mineral 
oil for a long time is not good treatment. Coating the stomach 
and intestines with continued doses of oil can but inhibit the 
digestive juices, and also must inhibit the absorption of nutri- 
ment. It may be a good treatment for those who eat too much. 
Very fine emulsions of mineral oil are now obtainable, but more 
bulk of the emulsion must be taken than of the oil itself. This 
mineral oil fad has probably reached its height. 

Podophyllum. — May apple has long been used in combination 
with other laxatives, and best in the form of the official resin, 
the dose of which is 0.01 Gm. (J£ grain). This drug acts slowly, 
generally in about twelve hours, and, as it is more irritant than 
the other drugs of this class and is likely to cause griping, it is 
rarely given alone. The very fact that it is more active than 
the other laxatives should preclude its use for any length of time, 
as it tends to cause irritation and to prolong the need of the 
bowel for a stimulant drug. 

Cascara Sagrada. — Cascara is one of the best laxative drugs. 
The official extract is the preparation most frequently used, 
given in the form of pills or tablets in from 2 to 5 grain doses. 
This preparation, however, is often almost inert. More effi- 
cient is the official Fluidextract of Cascara Sagrada, but it is 
very bitter and disagreeable to take. An aromatic fluid extract 



164 THE PRINCIPLES OF THERAPEUTICS 

is official, which is a pleasant preparation and especially adapted 
for children. It contains, besides cascara, licorice, glycerin and 
several spices, and is sweetened with saccharin. The Pharma- 
copoeia states the average adult dose to be one-half a teaspoon- 
ful, but generally 1 or 2 teaspoonfuls are required. The dose 
of this very pleasant tasting laxative may be easily computed 
for children from the adult dose. As it is perfectly harm- 
less, the dose is always sufficient to act in the individual 
patient. 

Many patients who suffer from constipation may be cured by 
slowly diminishing the dose that has been at first found suffi- 
cient. This drug is often well administered three times a day, 
in small doses, but most patients prefer the single dose after the 
evening meal or at bedtime, as it takes from eight to twelve 
hours to act. The drug may be combined with other laxatives, 
but as it does not gripe, it is best administered in a sufficient 
dose, uncombined. 

Cascara may be given when there are hemorrhoids, in preg- 
nancy, and when there is pelvic irritation, as it does not cause 
pelvic congestion. 

Rhubarb. — Rhubarb is not only a laxative, but is also some- 
what of a bitter tonic. In large doses it is almost an irritant 
cathartic, hence rhubarb should not often be used when there is 
inflammation of the intestines. It is also doubtful if rhubarb 
uncombined is a good drug to be frequently used as a laxative, 
as its action often produces a subsequent constipation, or its 
continued action may cause irritation. As rhubarb contains 
chrysophanic acid, it may cause the urine to be yellow, and 
even present the appearance of bilious urine. This yellow 
urine will turn to purple or red if it is made alkaline. Rhubarb 
is excreted in the milk and may affect a nursing child, when 
taken by the mother. 

The most frequently used rhubarb preparation is the Com- 
pound Rhubarb Pill, each pill of which contains 2 grains of 
rhubarb and 1^ grains of aloes. This pill is a stimulating 
laxative, but for the reasons above stated, rhubarb should not 
be given for any great length of time. A pleasant preparation 
of rhubarb for children is the aromatic syrup. The Pharma- 



LAXATIVES 165 

copoeia also recognizes an aromatic tincture, and the Compound 
Rhubarb Powder (Gregory's Powder). This contains 25 per 
cent, of rhubarb, 65 per cent, of magnesium oxide, and 10 per 
cent, of Jamaica ginger. The dose of this mixture is 2 Gm. 
(30 grains). It is not pleasant to take, and is probably rarely 
needed. 

Phenolphthalein. — This chemical drug, a much lauded laxa- 
tive, is best given in a tablet, which should be well chewed 
before swallowing. It is pleasant to take, as it is tasteless, and 
for children is generally given in a sweetened tablet. For a 
short time it is a well acting laxative, but it may soon cause 
irritation of the intestines, especially of the large bowel. 

This drug has been added surreptitiously to many laxative 
foods, such as biscuits, crackers, and even confections, and 
these preparations are urged as laxatives for children. Such 
a use of this drug is inexcusable, as it can do harm both to the 
bowel and, rarely, to the kidneys, especially when it is taken for 
a considerable length of time. 

Senna. — Senna is one of the simplest and one of the best of 
the laxatives. It can be taken for a long time without harm, 
does not leave an after effect of constipation, and is non- 
irritant. Frequently the leaves are chewed and swallowed be- 
fore bedtime ; or they may be chopped up with figs and taken 
as a confection. The Compound Licorice Powder, as before 
stated, has a laxative effect largely due to its senna. The 
official Fluidextract of Senna is one of the best liquid prepara- 
tions of this drug, and the average dose is half a teaspoonful. 

Sulphur. — Sulphur is now rarely used as a laxative except in 
the combination of the Compound Licorice Powder. It 
produces a disagreeable gas in the lower intestine, and some- 
times gives the odor of sulphur to the breath and to the per- 
spiration ; but as a simple laxative it is efficient, producing soft, 
pultaceous, and generally not watery, stools. The preparation 
of sulphur used as a laxative is the official Sulphur Lotum, 
washed sulphur. The dose is 4 Gm. (1 drachm). 

Many of the laxative drugs slightly stimulate the uterus, 
probably not enough to cause abortion, but often enough to 
hasten menstruation, if it is due. This is especially true of 



1 66 THE PRINCIPLES OF THERAPEUTICS 

podophyllum, aloes and rhubarb; even senna and cascara may 
cause some slight stimulation of the uterus. Many of these 
drugs are excreted in the milk. 

PURGATIVES 

Large doses of most of the above laxative drugs will cause a 
purgative action, but if such action is desired, it is better 
caused by calomel, castor oil, or a saline purge. 

Calomel. — The routine use of calomel or of any other form of 
mercury as a purgative in the beginning of every acute disease 
is, of course, a mistake. Not infrequently, however, a small 
dose of calomel combined with some other drug, as aloin, 
rhubarb, or senna, is good treatment in the beginning of many 
diseases. Such a dose of calomel may be advisable in the 
beginning of the treatment of constipation, of an acute indiges- 
tion, or of an acute diarrhea. The dose need not be large, but 
should be sufficient (from 0.05 to 0.10 Gm. (about 1 to 2 
grains), rarely more) and best given with an alkali, as the 
bicarbonate of sodium 0.50 to 1 Gm. (7 K to 15 grains), and not 
on an empty stomach. Calomel should be given with some 
simple food, as milk, or malted milk, or with crackers and 
water. Ordinarily it will take from five to eight hours for 
calomel to cause cathartic action; therefore it is the cathartic 
of choice when one must be given at bedtime. One grain or 
one and a half grains of calomel given at night with an aloin 
tablet, of the combination above suggested, will cause good 
catharsis in the morning. If for any reason the calomel action 
is delayed, or if it is given alone, some saline purgative may be 
given in the morning. 

As soon as calomel reaches the intestine it is decomposed by 
the alkaline secretions into mercury and the yellow oxide of 
mercury, and therefore there is developed some antiseptic action 
in the intestine. But unless such antiseptic action of calomel 
in the intestine is intended, as may be desirable at times in 
intestinal disturbances of young children, calomel should not 
be given in divided doses. In other words, the fad of }{ of a 
grain of calomel every half hour or hour until a grain or more 
has been taken is bad medication. The first doses of the calomel 



PURGATIVES 167 

are causing irritation before the last dose has begun to act. 
The result is duodenal irritation, often nausea and vomiting, 
and perhaps loss of appetite, without efficient movement of the 
bowels. Salivation may even be caused by such medication. 
It is much better to select the dose of calomel deemed best and 
give it all at once. The }{q grain calomel treatment to cause 
movement of the bowels after an operation is very prevalent, 
but deplorable. 

Castor Oil. — This cathartic oil is still the old stand-by for 
purgative action from childhood to old age. Although it 
develops in the intestine a slight irritant which causes catharsis, 
it never causes inflammation, and may even soothe an inflamed 
membrane. It causes catharsis that is not active, so that little 
harm can be done in intestinal obstruction or in appendicitis. 
If castor oil does not act on account of intestinal obstruction, 
other cathartics should generally not be given. Castor oil acts 
in from three to six hours, and therefore should not be given at 
bedtime. 

Almost tasteless castor oil can now be obtained, but it is 
never pleasant to take, although young children do not mind it. 
It is well given in an effervescing water, or added to some soda 
fountain drink, especially to the preparations flavored with oil 
of wintergreen. At home it may be taken on black coffee, or 
may be given in a wineglass as follows : salt at the bottom of the 
glass, then cold water, then the oil is placed in the center of the 
glass, and the whole is swallowed at once, and the taste left is 
that of the salt. Or it may be administered on lemon juice and 
cracked ice. The dose is from a teaspoonful to two tablespoon- 
fuls, the usual dose for an adult being one tablespoonful, or half 
an ounce. Large flexible capsules of castor oil may be swallowed 
after the capsule is moistened. Many individuals can swallow 
capsules better with a warm liquid, as milk, coffee, tea, or 
malted milk, than they can with plain water. In swallowing 
all pills and capsules the head should be thrown forward, not up 
and back, and the difficulty of swallowing them will be very 
much lessened. 

The National Formulary offers an aromatic preparation of 
castor oil that is not unpleasant. 



1 68 THE PRINCIPLES OF THERAPEUTICS 

SALINE PURGATIVES 

The saline purgatives act mostly as such by causing an in- 
creased amount of water to remain in the intestine or to be 
passed into the intestine by osmosis, so that the weight of the 
increased liquid in the intestine is what really causes the purga- 
tive action. For this very reason a saline purge will act better, 
more rapidly and more efficiently, if the patient is up and about. 
The salts that are the slowest to be absorbed from the intestine 
are those that act the best as purgatives. Those that are the 
most readily absorbed are those that act the least efficiently as 
purgatives. 

Salines interfere with the absorption of water that reaches 
the intestines, and, if in concentrated solutions, they may, by 
osmosis, cause water to pass from the blood into the intestine. 
Hence when they act, all this water is evacuated, and the patient 
often feels faint and thirsty. Magnesium sulphate seems to be 
converted in the intestine into magnesium bicarbonate and 
sodium sulphate, and this combination makes a more active 
watery purge than is caused by some of the other salines. Un- 
less there is some special reason why salines should be given 
concentrated, they should be administered well diluted. If given 
in strong solutions they are likely to remain in the stomach 
until enough water has been acquired to render the solutions 
isotonic, and during this process irritation of the stomach 
mucous membrane is caused and the passage into the intestine 
is delayed. When the saline solutions enter the intestine, if 
there is no obstruction to peristalsis, they are rapidly passed 
along and evacuated in anywhere from one to four hours. If 
anything prevents peristalsis or slows peristalsis, catharsis may 
not occur, or there may be several small troublesome movements 
instead of the complete evacuation. If the patient lies in bed, 
or is under the influence of some narcotic drug, or if the dose is 
not large and he goes to sleep, peristalsis is delayed and the 
evacuation of the bowels is delayed, and efficient action of the 
saline does not occur. Also, for the reasons above stated, if a 
saline is taken at night it may not cause catharsis, as the night 
rest may allow time for the water that the salt has retained to 



SALINE PURGATIVES 



169 



be re-absorbed with some of the dissolved salt, and the absorbed 
salt may have slight diuretic action. 

It has been shown that magnesium sulphate, Epsom salt, 
tends to increase acidity of the urine, and the reverse is true of 
sodium sulphate, Glauber's salt. This is one more reason that 
in serious toxic conditions magnesium sulphate, the most used 
saline cathartic, is not the safest drug to administer, in fact, 
other salines should preferably be used. Also, if for any reason 
the magnesium ion is absorbed, an added nervous depression 
will occur. It is doubtful if salines really expell many toxins or 
pathogenic germs from the intestines. The salines have their 
value in causing quick evacuation of the bowels, but they are 
used too freely and too much in serious conditions without tangi- 
ble therapeutic results, and often to the patient's harm. 

Theoretically, the more concentrated the salt solution that 
is taken the more water will be drawn from the body to the 
intestines; therefore to deplete the system or to aid in causing 
absorption of exudates the saline cathartics are given in con- 
centrated solution. 

Most salines will act in from two to four hours, if the dose 
given is sufficient, and when they act with this rapidity most of 
the salt is excreted in the stools. 

A not bad tasting, saline purgative is the official Pulvis 
Effervescens Compositus, known as the Seidlitz powder. This 
official preparation is put up in two papers, the blue paper 
containing sodium bicarbonate and potassium and sodium tar- 
trate (Rochelle salt), the white paper containing tartaric acid. 
The contents of one paper should be dissolved in one-third of 
a glass of water, and the contents of the other paper in one- 
third of another glass of water; they should then be poured 
together slowly so that the effervescence will not be too turbu- 
lent and a part of the solution be lost. It should then be slowly 
drunk while it is finishing effervescing, not while it is in 
violent ebullition, lest too much distention of the stomach be 
caused. 

A pleasant saline solution is the official Liquor Magnesii 
Citratis, which is an effervescing preparation of magnesium 
citrate. It is prepared in twelve-ounce bottles, and the whole 



170 THE PRINCIPLES OF THERAPEUTICS 

of it is not a large dose, although two-thirds of it is often 
sufficient. It is a palatable sour drink. 

Sodium Phosphate tastes like table salt, and is rather nau- 
seating unless it is taken well diluted or in lemonade; or it may 
be taken in an effervescing mixture. It is a mild purgative in 
the dose of 4 Gm. (1 drachm). An effervescing preparation is 
official. 

Potassium and Sodium Tartrate (Rochelle salt) is an efficient, 
not bad tasting preparation, and the dose is 15 Gm. (about 4 
drachms) taken well diluted. 

Magnesium Sulphate (Epsom salt) is the most efficient of the 
saline purgatives, it is bitter and salt at the same time, and very- 
disagreeable unless taken in an effervescing mixture. The dose 
is 15 Gm. (about 4 drachms). If the saline is likely not to act 
quickly and hence may be absorbed, some salt other than magne- 
sium sulphate should be selected, as magnesium may be seriously 
depressant. 

Sodium Sulphate (Glauber's salt) is the most disagreeable of 
the salines and is nauseating to most individuals, but it is effi- 
cient and useful, and is preferred by some physicians. The 
dose is 15 Gm. (about 4 drachms). 

Carlsbad Salt varies slightly in its composition, but generally 
it is composed of sodium sulphate 4 parts, sodium bicarbonate 
2 parts, and sodium chloride 1 part. Therefore it will be seen 
that any combination of a saline laxative with an alkali will 
be as efficient as this much used and much advertised saline. 

The saline purgatives may be given at any time, except late 
in the evening. They are best given before breakfast, and act 
most efficiently when given in hot water. 

The indications for the use of the saline cathartics are when 
rapid evacuation of the bowels is desired, and when castor oil 
is not preferred. They are also used in regular daily morning 
doses to cause depletion in plethora, in high blood-pressure, and 
when it is deemed advisable in kidney insufficiency. It should 
be emphasized that it is not always well to use salts that may be 
more or less absorbed and cause more or less difficult excretion by 
insufficient kidneys. The saline purgatives have been used too 
much, and the value of the salines in causing excretion of sys- 



IRRITANT PURGATIVES 171 

temic toxins through the bowels has been over estimated. The 
salines, when given in concentrated solutions and when the 
amount of water ingested is diminished, may cause absorption 
of exudates and effusions. 

IRRITANT PURGATIVES 

The drastic or irritant purgatives that are most used are 
colocynth, croton oil, elaterium, and jalap. Colocynth is 
never used alone, but always in combination with some other 
cathartic. It is doubtful if the drug is needed. 

Croton oil is a very rapidly acting cathartic, and in some 
comatose conditions, when there is no obstruction of the bowels 
it has therapeutic value. 

Elaterium has been much used to cause watery purging, with 
the object of eliminating toxins, by the bowels, that cannot be 
excreted by deficient kidneys. It is doubtful if nitrogenous 
poisons can be much eliminated by this method. Elaterium has 
also been much used in dropsies, with the object of eliminating 
large amounts of water by way of the intestines, thus promoting 
absorption and aiding the removal of effusions. It is thought 
to be especially valuable when the kidneys do not work and diu- 
retics are not satisfactory. Catharsis from this drug is very 
weakening, and unless the heart is strong, the drug should not be 
used. 

Jalap is generally given in combination with some other 
cathartic, also with the object of causing watery stools, and 
therefore depletion. Its action is not so depressant to the 
circulation as is elaterium. 

To sum up the discussion of irritant purgatives, it may be 
stated that croton oil is rarely needed, but is a most efficient, 
quickly acting cathartic ; that elaterium is very rarely indicated ; 
and that jalap may be occasionally used. These drugs have 
come into disrepute because it has been found that large 
depletion by the bowels is very depressant to the circulation, 
and that in most dropsies there is cardiac insufficiency, and 
anything that increases that insufficiency is serious for the 
patient. Many a patient with cardiac dropsy has had his 
death hastened by profuse catharsis. Another reason that 



172 THE PRINCIPLES OF THERAPEUTICS 

these drugs have come into disrepute is because it has been 
learned, as above stated, that in insufficiency of the kidneys the 
irritants that are retained in the blood and act as toxic poisons 
cannot be eliminated in any great amounts by profuse purging. 

Colocynth (Bitter Apple) when used at all is given in combi- 
nation with other drugs. It is an active irritant cathartic, 
and would not be mentioned here if the official Compound 
Extract of Colocynth (which contains, besides colocynth, aloes 
and resin of scammony) was not, unnecessarily, frequently 
added to cathartic combinations. It is also mentioned because 
it enters into the combination of the Compound Cathartic 
Pill, which is used so largely in all hospitals. 

Croton Oil is a yellow fixed oil, irritant to the skin and mucous 
membranes. When rubbed on the skin it will cause a pustular 
eruption, and has been used as a counterirritant, but is now 
rarely used externally. Internally it is an irritant, unless well 
diluted. When absorbed from any part of the alimentary canal 
it will soon cause purging. Over-action of this drug, as of any 
of the other irritant cathartics, will cause an inflammation of 
the intestine. The dose is one or two drops, well diluted. If 
the patient is comatose, it may be given on granulated sugar for 
absorption in the mouth. Catharsis generally occurs in from 
one to two hours. 

Jalap is used only in some preparations. It is an active, 
mildly irritant cathartic, causing watery movements in three 
or four hours. It enters into the combination of the Compound 
Cathartic Pill in the form of the official resin. The best 
preparation of jalap, if watery movements of the bowels are 
desired without danger of much irritation or much depression, 
is the official Pulvis Jalapoz Compositus. This powder contains 
35 parts of jalap and 65 parts of potassium bitartrate, and the 
dose is 2 Gm. (30 grains), which may be repeated in four to 
six hours, if it has not satisfactorily acted. 

Compound Cathartic Pills are ancient and fairly honorable, 
but are certainly not up to date. Few prescribers recognize 
that this pill represents a combination of eight ingredients, 
namely, colocynth, aloes, scammony, calomel, jalap, gamboge, 
cardamom seed and soap. This shotgun prescription may 



TO DIMINISH INTESTINAL PUTREFACTION 1 73 

produce the desired results, but its use is simply a matter of 
habit. Other more simple purgatives will succeed as well, and 
in this age of simplicity in the medicinal treatment of disease the 
compound cathartic pill should be eliminated. 

DRUGS USED TO DIMINISH INTESTINAL PUTREFACTION 

It has long been a question of doubt as to the efficiency of the 
so-called bowel antiseptics. Certain specific germs can be 
killed in the intestine with special germicides, but, of course, 
it is impossible to render the intestines aseptic. On the other 
hand, the different flora of the intestines can be changed, not 
only by diet, but by drugs. A change from an animal protein 
diet to a vegetable diet will change the intestinal flora. A 
change from a mixed diet to a pure milk diet, or the reverse, 
will also change the intestinal flora. Probably many drugs act 
as antiseptics in the upper part of the intestine; most of the 
salicylic acid preparations and some of the phenol combinations 
have such action. Perhaps some of the synthetic drugs, es- 
pecially the antipyretics, and some of the metallic drugs, 
especially calomel, will have some antiseptic action in the upper 
part of the intestines; but the drugs that are most successful in 
causing some sort of antiseptic action in this region are beta- 
naphthol and salol. Betanaphthol can act as a depressant poison, 
and consequently, except when intestinal parasites are to be 
eradicated, the drug should not often be used in intestinal 
putrefaction. Salol (phenyl salicylate) is the best of the bowel 
antiseptics, as it is changed in the upper intestine (in alkaline 
solutions) into salicylic acid and phenol. In ordinary doses 
for a short length of time it is non-poisonous, and the only 
symptoms of poisoning are those of a weak phenol. 

The most successful method of diminishing intestinal putre- 
faction is by a radical change in the diet in which all protein is 
temporarily removed, especially all meat proteins. Various 
forms of lactic acid bacilli and various forms of fermented milk 
are used to check putrefaction. 

It has long been considered that the B. hdgaricus was the best 
of the lactic acid bacilli for the purpose of changing the bacterial 
flora in the intestine and for preventing putrefaction. Lately, 



174 THE PRINCIPLES OF THERAPEUTICS 

however, Rettger 1 has shown that this bacillus cannot be trans- 
planted into the intestine, but that it allows to develop the B. 
acidophilus, a normal constituent of the intestine, and it is this 
bacillus which is capable of changing the intestinal flora. Con- 
sequently, theoretically it would seem more logical to administer 
directly the B. acidophilus, perhaps preferably as milk soured 
by this germ. Besides the various forms of bacillary milk 
offered, liquid cultures may be obtained and taken with water 
or the tablets of Bulgarian bacilli may be chewed up and swal- 
lowed after meals. If the food previously taken has not 
contained starch and sugar, a small amount of sugar, best 
sugar of milk, should be eaten or taken with the tablets or 
culture. 

Yeast, both brewers' yeast and the ordinary compressed 
yeast, is valuable in changing the intestinal flora. The organism 
this yeast contains is the saccharomyces cerevisice. Yeast con- 
tains a large amount of nuclein. It may liberate lactic acid, 
and not only yeast preparations, but also the Bulgarian bacilli 
preparations, should not be given for any great length of time, 
as they tend to cause hyperacidity and joint pains. It is best 
to give lactic bacilli preparations intermittently, thus changing 
the intestinal flora for a time, then allowing the reverse change 
by stopping the treatment, and then to again give the bacilli. 
Lactic bacilli treatment combined with the proper diet will 
many times completely eliminate intestinal putrefaction. 

Yeast has long been administered in infections, and is fre- 
quently a very valuable treatment. It cleans the tongue, 
causes movements of the bowels, stimulates the production of 
white corpuscles, and seems at times to combat streptococcic 
infections. It has also been used locally for various purulent 
conditions in douches and washes. Brewers' yeast can be 
used in full strength or diluted for such purposes. Internally, 
the dose is a tablespoonful of liquid brewers' yeasty well diluted, 
or from 3^ to J^ of a compressed yeast cake, dissolved in a glass 
of water. This dose may be taken once, twice, or three times 
a day, as deemed advisable, the dose to be reduced, if it causes 

1 Proceedings of the National Academy of Sciences. Vol. 6, No. 7, p. 423 
July,. 1920. 



ANTHELMINTICS 1 7 5 

purging or nausea. This soured drink is not disagreeable to 
most people, and may be agreeable to those who have fever. 

Dried preparations of brewers' yeast may be obtained, but 
they are not quite as satisfactory as are the fresh preparations. 
The dried brewers' yeast is quite efficient as a carrier of vita- 
mines that are activators of nutrition and stimulants to the 
appetite . The dose for this purpose is one gram (15 grains) three 
times a day, taken with the meals. Unless special care is taken 
in the method of drying and preserving this yeast, it readily 
becomes wormy. 

It has been learned that sugar of milk (lactose), dextrose 

(glucose) and dextri-maltose {i.e., dextrine and maltose) act 

more or less as preventives of intestinal putrefaction. They 

are therefore valuable additions to the foods of individuals who 

are suffering from that condition, and prevent such putrefaction 

when added to the milk and other artificial food of young 

children. 

ANTHELMINTICS 

The intestinal parasites that are common and must be medicin- 
ally eradicated are the tapeworms {tenia), of which there are 
three principal varieties, the pork, the beef, and the fish, the 
last being rare in this country; the round-worm {ascaris lumbri- 
coides) ; the pin- worm {oxyuris vermicularis) ; and the hook- 
worm {necator Americanus). Another chronic infection of the 
intestine is the ameba, the cause of amebic dysentery. Acute 
infections of the intestines, as occur in typhoid fever, and carriers 
of pathogenic germs in the intestines, are not cured by anthel- 
mintics. The stools of all patients who have intestinal para- 
sites of any kind should be disinfected. 

Tape-worms. — The drugs used to eradicate tape-worms are, 
aspidium, pelletierine tannate, and pumpkin and squash seeds. 
Pomegranate has also been used for this purpose. Pumpkin and 
squash seeds are harmless and infusions (not boiled) of 
ground pumpkin or squash seeds are often very successful in 
eradicating the worm. A treatment is not successful unless the 
head of the tape-worm is eliminated. The most used drug 
is aspidium (male fern), but a drug much in vogue to-day is 
pelletierine tannate. 



I76 THE PRINCIPLES OF THERAPEUTICS 

An anthelmintic should not be given until the patient has 
been previously more or less starved. Toward that end, free 
purging (Jdv some saline cathartic) is caused in the afternoon of 
the day before the treatment is to be begun, and the patient has 
only some light liquid food for supper that evening, as a cup of 
gruel or a bowl of soup. Early in the morning the patient 
should take the male fern as directed : 

Oleoresin aspidium 4 Gm = 

Make eight capsules. 

Take four capsules with half a glass of hot water, and the 
remaining four capsules in an hour with more hot water. The 
capsules should be uncapped before swallowing. 

In two more hours the patient should receive an ounce of 
Epsom or Rochelle salt, well diluted, thus to insure the rapid 
passage of the aspidium with the stupefied worm through the 
alimentary canal. 

Neither castor oil nor any other oil should be given a patient 
who has taken aspidium, as oils promote absorption of the drug 
and therefore poisoning. 

If during the time of the administration of these drugs the 
patient is faint, he may have clear tea, coffee, or bouillon. Also 
he may be given a dose of strychnine. One hour after taking 
the Epsom or Rochelle salt he may have a cup of cereal gruel, or a 
poached egg, or some broth. The patient should He down, 
except when it is necessary that he be up. He should not be 
left alone, and must have nearby conveniences for movements 
of the bowels, as he is likely to become faint from the severity 
of the treatment. Either a trained nurse or a physician should 
stay with him during the hours of the active treatment. If the 
head of the tape-worm is obtained, the patient's troubles are 
ended, unless he has more than one worm. 

Treatment with other vermifuges require the same privation 
of food and about the same method of procedure on the day 
of the administration of the active drug. If pelletierine tannate 
is used, the dose is about 0.30 Gm. (5 grains), given in water. 

Aspidium (Male Fern) is administered as the oleoresin, and 
is used only for the eradication of tape- worms. The method of 



ANTHELMINTICS 1 7 7 

its administration is as above described. In overdoses, or 
when it is long contained in the intestine (i. e., when cathartics 
do not act thoroughly after it has been ingested) it will cause 
vomiting, diarrhea, tremors and convulsions. The dose of the 
official oleoresin is 2 Gm. (30 grains). This dose may 
be repeated within an hour, if the patient is a strong 
adult, to insure its efficient action. If the patient is weak, or is 
a child, the dose of course should be diminished; but the danger 
of poisoning lies not so much from the size of the dose as from 
the length of time it remains in the intestines. Purging must be 
caused in two or three hours after the final dose has been taken. 

Pelletierine T annate is a mixture of the tannates of four al- 
kaloids, occurs as a yellowish powder, and has a slightly astrin- 
gent taste. It is used only for the eradication of tape-worms. 
The dose is about 0.30 Gm. (5 grains), taken with plenty of 
water, with the preparatory and after treatment as above 
described. 

Round-worms. — The round-worm is not very frequent, as 
children do not now have the opportunity of, and are prevented 
from, eating infected food and drinking infected water. Unless 
worms have been found in the child's stools, the symptoms as- 
cribed to them should not be considered as causing more than a 
possible diagnosis. A worm having been found in the stools, 
there are probably more, and the best drugs to eradicate them 
are santonin, thymol, spigelia, and wormseed oil. Santonin 
is perhaps the most used, and is well given in the following 
combination : 

Santonin o . 30 Gm. 

Calomel o. 20 Gm. 

Milk sugar 3 • Gm. 

Make ten powders 

Take a powder, with water, every hour, for three doses. A 
starvation period should precede the santonin, and some laxa- 
tive, such as the citrate of magnesium or a Seidlitz powder (the 
amount depending upon the child's age) should be given two 
hours after the last dose of the santonin has been taken. Neither 
castor oil nor other oils should be given in conjunction with 
santonin, as oils promote absorption and poisoning. 
12 



178 THE PRINCIPLES OF THERAPEUTICS 

It will likely be necessary to repeat this same treatment in a 
week, and perhaps again in two weeks, to be sure that all the 
worms are eliminated. 

Wormseed oil has often been given to eradicate round-worms 
in a dose of five drops, on sugar, repeated in an hour. The 
treatment should be preceded by a starvation period and a 
cathartic, and be followed by a cathartic. 

Santonin occurs as colorless, shining prisms or as a crystalline 
powder, insoluble in water, and is best given in combination 
with a cathartic, as above suggested. As it is very poisonous, 
and may affect the eye-sight, and may cause tremors and con- 
vulsions, it should not be given by druggists to mothers for their 
children without a physician's perscription; the promiscuous 
administration of santonin tablets is inexcusable. 

Betanaphthol (Naphthol) is a phenol, and occurs as a yellow- 
ish-white crystalline powder, practically insoluble in water, but 
very soluble in alcohol. It has been used as an external antisep- 
tic, and is an intestinal antiseptic and germicide. It may cause 
poisoning, with symptoms similar to phenol poisoning, or it may 
cause destruction of red blood cells, and, although frequently 
successful as an anthelmintic, other drugs are better and safer. 
The dose of betanaphthol is 0.25 Gm. (4 grains), best given in 
capsules. 

Spigelia (Pinkroot) has long been used as an anthelmintic, 
for round-worms especially, although it has also been used for 
pin-worms. It is a non-poisonous, mild anthelmintic, best 
administered as the official fluidextract, and best combined with 
a laxative. The most satisfactory combination is with the 
fluidextract of senna. These preparations may be combined 
in equal parts, and the child having been without food for a 
number of hours, a teaspoonful of this mixture may be given 
every hour for three doses. If in a few hours the bowels do 
not move, a more active purgative may be administered. 

Pin-worms. — These small worms occur in the rectum and 
cause very troublesome irritation, and often eczema develops 
from the scratching. The most used preparation to eradicate 
these worms is a decoction of quassia. The decoction is made 
by placing 50 grams of quassia chips in 750 mils of water and 



ANTHELMINTICS 1 79 

boiling it down to 500 mils. This strained solution is then in- 
jected into the rectum which has been previously washed with 
a weak soap and water enema. This treatment must be repeated 
for many days. Injections of glycerin and water have also 
been used, and also bisulphate of quinine solutions, in about 1 
per cent, strength, are often successful. The bowels must move, 
daily, with some simple laxative, as senna, and it may be well to 
give a few doses of spigelia, as above suggested for round-worms. 
The local eczema should be treated with a weak phenol oint- 
ment. Infants and young children should be so clothed that 
their fingers cannot become contaminated and make re-infection 
possible. 

Hook-worms. — This very common cause of general debility 
and anemia in the Southern States can be completely cured, and 
will probably gradually be eradicated. The treatment is with 
thymol or worm-seed oil. The preparatory treatment is much 
the same as has been described under the treatment of tape- 
worm. After the bowels have freely moved in the morning, 
one-harf the dose decided upon is given, and the other half is 
given in two hours. The dose of thymol must be large to be 
effective, and the adult dose should be 3 or 4 grams (45 to 60 
grains). The dose for children should be computed from this 
adult dose; a ten-year old child should receive half the dose; 
a five-year old child one-quarter of the dose, etc. Ferrell be- 
lieves that thymol acts better when combined with an equal part 
of sugar of milk. It is best administered as a powder, in cap- 
sules, and the capsules should be uncapped at the time of 
swallowing. Two hours after the last dose of thymol, half an 
ounce to an ounce of Epsom salt, or Rochelle salt, should be 
taken, this to be repeated if the bowels have not moved in four 
hours. The danger from thymol lies in its absorption, and the 
longer it remains in the intestine, the more likely is absorption to 
occur. When the patient is reclining he should lie on his right 
side to facilitate the passage of the thymol into the intestine. 

Wormseed oil has been shown to be as effective as thymol in 
eradicating hook-worms, and it is not as poisonous a drug. 
While wormseed oil does not kill the hook-worms, it seems to 
stupefy them, and if, after a short action of the wormseed oil, 



I So THE PRINCIPLES OF THERAPEUTICS 

a brisk cathartic is given, the worms are passed out of the 
bowels. While castor oil or any other kind of oil must not be 
used as a cathartic after thymol treatment, castor oil may be 
riven as a cathartic after wormseed oil has been administered. 
The dose of wormseed oil suggested is one drop for every year 
of the age of the child up to fifteen years. It may be given on 
granulated sugar. This dose may be repeated every two hours 
for three doses, and two hours later the child receives a full dose 
of castor oil. The preparatory treatment is the same as when 
other anthelmintics are used; i.e., a starvation period, then 
purging, and later sustaining treatment. 

As it is difficult to eradicate hook-worms at one treatment, 
the anthelmintic may have to be repeated several times at six- 
day intervals. Whenever depression occurs from these treat- 
ments, coffee, caffeine, atropine, and other cardiac stimulants 
may be needed. Throughout the treatment the patient should 
be under the careful observation of the physician. 

Thymol is a phenol, and occurs as colorless prisms, practically 
insoluble in water, very soluble in alcohol, and has a pungent, 
aromatic taste. It is often added to gargles and sprays, in 
weak solutions, for its antiseptic action, and has been used as a 
bowel antiseptic, but it should not be used internally except 
for the specific purpose of eradicating hook-worms, as it is a 
drug which may readily cause poisoning. The poisoning that it 
causes is typically of the phenol type; it may cause nausea, 
vomiting, sweating, dizziness, and collapse. It may cause the 
urine to become dark or greenish, and it is more or less irritant 
to the kidneys. The intestinal antiseptic dose is o.io Gm. 
(about 2 grains), best given in capsules. The Pharmacopoeia 
gives the anthelmintic dose as i gram (15 grains), but in the 
treatment of hook-worm disease much larger doses must be 
given, as above described. 

Carvacrol is produced from spruce turpentine, is similar to 
thymol, and costs much less. Before this drug is used inter- 
nally as a substitute for thymol in hook-worm disease it 
must be more thoroughly investigated. 

Oil of Chenopodium (Wormseed Oil) is a pale yellowish 
liquid, having a disagreeable taste and odor. This oil has been 



ANTHELMINTICS l8l 

used to expel round-worms, but more especially, as just stated, 
for the eradication of hook-worms. It has no other uses. The 
United States Pharmacopoeia gives the dose as 0.2 mil (3 
minims). The dose may be considered, as above described in 
the treatment of hook-worm, about 15 drops for an adult for 
any one day. 

At times oil of chenopodium may show no serious symptoms 
on the day of its first administration, but when it is repeated 
several days later there may be found an increased hyper- 
susceptibility to it. This is especially true if the individual is 
under-nourished. A cachectic child or older patient should 
probably not receive the second treatment from the oil of cheno- 
podium unless his nutrition has improved, and he has taken a 
goodly amount of food. Castor oil given before and after the 
administration of wormseed oil has seemed to prevent toxic action 
from the latter. Also, plenty of water should be taken with the 
oil to insure its rapid passage from the stomach to the intestine. 

Amebic Dysentery. — Fortunately, this disease is not frequent 
in all parts of this country, but it is common in the tropics. 

The specific treatment of amebic dysentery is the adminis- 
tration of ipecac and emetine. The ipecac is administered by 
the mouth, perhaps best in the form of emetine bismuth iodide, 
as the ipecac in the intestines better eradicates the ameba that 
are on the surface of the intestinal walls than does the dose of 
emetine given hypodermatically. Emetine given hypoder- 
matically will kill the ameba that are deeper in the tissues of 
the intestinal walls. When ipecac is administered by the 
mouth in a form that is insoluble in the stomach, it is not 
necessary to precede the dose with opium or morphine, but in a 
form that is irritant to the stomach, vomiting will be caused 
unless a hypodermic of % to }i of a grain of morphine has 
been previously administered. The Pharmacopceial hypoder- 
matic dose of this preparation is stated to be 0.02 Gm. (J^ 
grain), but when this is to be repeated, as in amebic dysentery, 
the dose should be smaller, perhaps about 0.01 Gm. given once 
or twice a day, hypodermatically, for three or four days, and 
then once a day for a week, this combined with the administra- 
tion of some form of ipecac by the mouth. 



1 82 THE PRINCIPLES OF THERAPEUTICS 

It should be noted that emetine in too large doses may cause 
some paralysis and heart weakness, and may cause death. 

The best preparation for administration by the mouth is 
perhaps emetine bismuth iodide, which may be administered 
in 0.05 Gm. (about 1 grain) doses three times a day, for two 
weeks. According to Sollmann 1 this preparation is but slightly 
soluble in the stomach, and seems to be freely soluble in alkaline 
media. Therefore it is soluble in the intestine. 

Emetine Hydrochloride is the hydrochloride of the alkaloid 
emetine, which is obtained from ipecac. It is a yellowish 
crystalline powder, is soluble in water, and is used mostly 
hypodermatically as a specific in amebic dysentery. Its value 
in pyorrhea alveolaris has not been proved. The single dose 
is 0.02 Gm. (3^3 grain) hypodermatically. 

Emetine Bismuth Iodide, N .N.R. is a complex iodide of 
emetine and bismuth, containing not far from 20 per cent, of 
anhydrous emetine and about 20 per cent, of bismuth. It 
rarely causes vomiting, and is a good method of administering 
ipecac for intestinal action. The dose is 0.20 Gm. (3 grains), 
given either in a single or in divided doses for several days, well 
administered in capsules. 

Alcresta Ipecac. — This is an emetinated fullers' earth. It has 
been shown by Sollmann that the alkaloids of alcresta ipecac 
are insoluble not only in the stomach but in alkaline media. 
Therefore they may not be dissolved in the intestines. 

Caution. — Emetine in any form should always be used with 
care, as it may cause poisoning. 

It should be emphasized that the ipecac and emetine treat- 
ment of amebic dysentery does not heal the ulcers in the intes- 
tines, and after the ameba have been eradicated, this surgi- 
cal condition requires further treatment. 

Leukemia. — Benzene (Benzol) has been recommended and 
used in leukemia, as by its administration the number of white 
corpuscles is reduced. This is especially true if the rcentgen- 
ray treatment is used coincidently. Several preparations may 
be obtained, and the dose of " benzene, medicinal," according to 

1 Journal A. M. A., Oct. 11, 1919, p. 1125. 



DIAPHORETICS 1 83 

New and Nonofiicial Remedies, is 0.5 to 1 mil (8 to 15 minims) 
given four times a day, best in emulsion. Treatment with this 
drug is not without danger, and the condition of the patient 
and the condition of the blood must be watched. Its perma- 
nent value in this disease has not been proved. 



SECOND DIVISION 
CLASS I 

Drugs Administered Internally For Their Action On 

The Skin 

drugs used to stimulate the activity of the skin 

The surface of the body is dry, scaly and harsh in various 
chronic diseases of the skin, and it is also dry in hypothyroidism, 
in chronic nephritis, and in diseased conditions of the liver. 
Any treatment that improves the systemic condition will 
improve the condition of the skin. Many times a dry skin — a 
skin that does not normally perspire — will be improved by the 
administration of thyroid extract, if such medication is not 
contraindicated. Arsenic is also a stimulant to the skin, but 
it should not be given if there is disease of the kidneys or 
liver. The majority of dry skins, not due to organic diseases, 
are due to sub-thyroid secretion. 

A description of the action of arsenic and of thyroid gland 
extracts will be found on pages 382 and 406 respectively. 

DIAPHORETICS 

It is desirable to increase the perspiration in fever, after 
chilling, and in some toxemias. The so-called antipyretic drugs 
all promote perspiration, and especially valuable for this ac- 
tivity is antipyrine. Alcohol, by dilating the peripheral blood- 
vessels, is a promotor of perspiration. 

Of all methods to promote perspiration, the best are body 
baking, electric light cabinet baths, Turkish baths, ordinary 
hot baths, and strenuous exercise. Turkish baths and exercise 
are especially valuable in reducing obesity by causing perspi- 



184 THE PRINCIPLES OF THERAPEUTICS 

ration. Most of these physical methods of causing perspiration 
are of value in aborting a cold after chilling. 

Profuse sweating has long been advocated in systemic 
conditions. Whether caused by pilocarpine, by dry hot air, 
or by moist hot air, the value of profuse perspiration in eliminat- 
ing toxins, particularly in uremic conditions, is very doubtful. 
The action of alcohol and of antipyrine are described on pages 
238 and 337 respectively. 

Pilocarpus. — Administration. — Jaborandi occurs as the dried 
leaves of a South American plant. The active part of this 
drug is represented by its alkaloid, pilocarpine. Pilocarpus 
is not used as such, but it may be used as the official nuidextract, 
the dose of which is 2 mils (30 minims). As the alkaloid 
represents the activities of the plant, the drug is best used in the 
form of the official Pilocarpines Hydrochloridum. This salt 
occurs in colorless crystals and is very soluble in water and 
alcohol. The dose by the mouth is 0.01 Gm. (}£ grain), and 
the hypodermic dose is 0.005 Gm. (}{2 grain). For quick 
action, the hypodermatic method is the better. 

Action. — Pilocarpus has no external action. It is rapidly 
absorbed, and stimulates the sympathetic nerves, sweat glands, 
and salivary glands. It also stimulates the bronchial glands, 
and may cause profuse bronchial secretion. Consequently, 
in prostration or in impaired circulation, and especially if there 
are signs of edema of the lungs, it should not be used, as it 
can literally cause drowning by the enormous watery secretion 
into the lungs that may occur. It may also lower the blood- 
pressure and weaken the heart, therefore, in any condition of 
depression pilocarpine should not be used. 

In about ten minutes after its administration by the stomach 
(unless something prevents its absorption), and in about five 
minutes when it is administered hypodermatically, flushing of 
the face and neck occurs, from dilatation of the peripheral 
blood-vessels; and in about fifteen minutes sweating begins, 
which may persist for one or two hours, or even longer. 

The slight stimulation of the endings of the vagi nerves will 
slow the heart, although the heart is not strengthened but is 
really weakened, and soon the least exertion may cause the 



DIAPHORETICS 185 

heart to become rapid. This is especially in evidence if the drug 
causes nausea or vomiting. Salivation may be profuse, the 
nasal secretion increased, and the lachrymal glands stimulated. 

Pilocarpine has been thought to stimulate the uterus to con- 
traction, and it may increase labor pains, but it should not be 
used for this purpose. When applied to the eye, it produces 
contraction of the pupil and increases the ocular tension. 

Over-action. — When this drug acts excessively, it not only 
causes profuse and prolonged sweating but also vomiting and 
diarrhea. It increases the secretion of the intestinal glands, 
and may disturb the pancreas and the glands of internal secre- 
tion, perhaps the suprarenal glands. 

Toxic Action. — Pilocarpine may cause dizziness, disturbed 
vision, cold perspiration, and collapse, and death may occur 
from pulmonary edema, or from heart failure. 

Treatment of Poisoning. — Besides evacuating the stomach, if 
the drug has been administered by the mouth or taken by 
accident, tannic acid should be given. The physiologic anti- 
dote to pilocarpine is atropine, which should be given hypo- 
dermatically. Atropine is directly opposed to the action of 
pilocarpine, namely, it inhibits the secretion of the skin and 
most of the glands of the body, stimulates the respiratory 
center, stimulates the heart and raises the blood-pressure. 

A patient suffering from pilocarpine poisoning should be 
surrounded with dry heat, and, besides the atropine, caffeine 
and strychnine should be administered. 

Uses. — The most important use of pilocarpine has been in the 
anasarca of nephritis and in uremia. The object was to pro- 
mote profuse perspiration, and therefore to eliminate water from 
the body and as many toxins as could be excreted by the skin. 
In uremic poisoning without general edema, the large excretion 
of water by the skin which pilocarpine promotes could do 
nothing but concentrate the toxins in the blood, and the amount 
of nitrogenous excretives that can be eliminated through the 
skin, even with profuse perspiration, is not great. More 
sodium chloride may be thus removed, but little urea is elimi- 
nated. Therefore, theoretically, this is not good treatment 
in such a condition; venesection would be better. On the 



l86 THE PRINCIPLES OF THERAPEUTICS 

other hand, if profuse sweating is advisable in such a condition, 
it is best promoted by some method of applying heat which 
would cause the same physical results without the prostration. 

If there is general anasarca, or even large localized edemas 
in nephritis, pilocarpine, by promoting a large excretion of 
water by the skin, if the patient is not allowed to ingest water, 
may cause resorption of the exudate. But while this process is 
going on the patient is likely to become debilitated. Edema 
with a weakened circulation, and certainly cardiac edemas, 
should not be treated by pilocarpine. If the kidneys are so 
damaged that applications of heat (if perspiration is desired) 
will not relieve the serious condition, neither will pilocarpine. 
Therefore pilocarpine treatment of serious conditions is gener- 
ally inadvisable. 

Pilocarpine has been suggested to promote secretion in the 
beginning of colds and acute bronchitis. The dose for this con- 
dition is small, and it is generally given by the mouth; but other 
treatments are better. 

Pilocarpine has also been suggested to promote the mammary 
secretion in lactation, but its action for this purpose is doubt- 
ful, as when the dose is sufficient to stimulate the mammary 
glands it will also be sufficient to promote perspiration, which is 
likely to diminish the lacteal secretion. 

The hydrochloride of pilocarpine has been used in i per cent, 
solutions in the eye for the same purpose as physostigmine 
(eserine) is used. It is a little less irritant than eserine, and, as 
above stated, will contract the pupils. Two or three drops of a 
i per cent, solution may be dropped into the eye, two or 
three times a day. 

Pilocarpine has also been used in certain skin diseases, as 
psoriasis and dry eczema, but in most of these chronic dry condi- 
tions of the skin thyroid extract acts better. It has also been 
used to promote the growth of hair in baldness, but it is doubt- 
ful if there is any good reason for such use. 

DRUGS USED TO DECREASE PERSPIRATION 

Profuse, weakening perspiration often occurs at the time of 
the crisis of a disease or at any time when there is a rapid fall of 



GENITOURINARY SYSTEM 1 87 

temperature in disease. It also occurs as a part of septic in- 
fection, is especially common in acute rheumatism, and is a 
serious symptom of tuberculosis. 

The treatment of profuse perspiration is the application of dry 
heat, and the administration of 3^oo to Moo grain of atropine 
sulphate. Preventive treatments are massage, warm alcohol 
rubs, circulatory stimulants, and anything that improves the 
general condition of the patient. 

SECOND DIVISION 
CLASS II 

Drugs used for their action on the Genitourinary 

System 

All vegetable foods and drugs of strong taste and smell are 
mildly diuretic, such as onions, garlic, radishes, celery, aspara- 
gus, asafetida, and valerian, as they are mild stimulants to the 
kidneys. All of the spices are more or less stimulant to the 
genitourinary mucous membranes, and hence should be avoided 
in kidney, bladder and other genitourinary inflammations. 
Tea and coffee should also be avoided when these regions are 
inflamed or irritated. All of the turpentines are stimulant to 
the kidneys, and in any large amount are irritant. 

Anything that irritates the kidneys, or any poison that is 
ingested and irritates them during its excretion will cause the 
following symptoms, in the order named: increased frequency 
of urination with diminishing amounts of urine passed; back- 
ache; perhaps vesical tenesmus and urethral burning; later 
an increased amount of mucus in the urine ; then albumin ; then 
blood ; and finally suppression ; and, after some drugs, strangury. 
The treatment of such an acute inflammation is that of acute 
nephritis. 

So-called diuretic drugs, whose names were legion, have 
become of less and less importance, until only a certain few have 
stood the test of efficiency and are of value. It is by no means 
always possible to increase the amount of urine, and especially 
is success often lacking when diuresis is most needed. 



lS8 THE PRINCIPLES OF THERAPEUTICS 

The amount of urine is increased : 

i. By increased blood-pressure. 

(a) Hypertension. 

(b) Increased heart action. 

(c) Cold to the surface of the body. 

(d) Nervous excitement (fear, hysteria). 

2. By drugs that raise the blood-pressure. 

3. By drugs or substances that stimulate the secreting epi- 
thelium of the kidneys. 

The amount of urine is diminished: 

1. By low blood-pressure. 

(a) Insufficiency of the heart. 

(b) Shock. 

(c) Hemorrhage. 

(d) Heat to the surface of the body. 

2. By drugs that lower blood-pressure. 

3. By fever. 

4. By kidney lesions. 

5. By pressure on the kidney blood-vessels. 

Therefore, to increase the output of urine, with the kidneys 
intact, we must raise the general blood-pressure by heart tonics 
or by vasocon tractors ; or we must increase the bulk of the 
blood (by water) ; or we must give drugs that actually stimulate 
the kidney epithelium. 

DRUGS USED TO INCREASE THE AMOUNT OF URINE 

The best drugs for this purpose are those listed in the classi- 
fication, but before administering such a drug, it is essential to 
note some general physiologic principles. 

The skin and the kidneys act and react upon each other; the 
more secretion or excretion by the skin, the less by the kidneys, 
and the reverse. If the skin cannot act during fever and is hot 
and dry, the kidneys soon become congested, and frequently 
excrete albumin. On the other hand, a profuse sweat during a 
feverish process may not only cause the urine to become con- 
centrated, but it may also cause it to contain albumin. When 



DIURETICS 189 

a large amount of skin has been destroyed by burns, and the 
secretion and excretion of the skin is seriously interfered with, 
the kidneys are likely to become irritated, and the urine to 
become albuminous. Any serious skin disease that attacks a 
large portion of the surface of the body, preventing its normal 
activity, may also cause kidney disturbance. The obverse 
of this is also true, namely, in chronic nephritis the skin is 
called upon to do extra work, and it, sooner or later, becomes 
dry, irritated, and perhaps eczematous. When this condition 
of the skin develops the prognosis of the kidney disturbance is 
grave. Acute inflammations that attack large surfaces of the 
body, as scarlet fever, erysipelas and small-pox, also tend to 
cause kidney irritation, congestion, and perhaps inflammation. 

In any of these conditions named treatment aimed at a modi- 
fication of the urinary secretion is advisable. If the urine is 
concentrated and diminished in amount, plenty of water should 
be ingested, with perhaps some non-irritating drug that 
would increase the output of the urine. Often, however, the 
kidneys should be relieved by causing the skin to become more 
active, by hot baths and hot drinks, or by other methods that 
cause perspiration. 

If albumin is found in the urine, the diet should be non-irrita- 
ting and bland ; often meat, tea, coffee, spices and condiments 
should be withheld, and no drugs should be allowed that could 
irritate the kidneys. If congestion of the kidneys has occurred, 
the treatment should be such as would prevent acute nephritis, if 
possible, and it may be inadvisable to push the ingestion of 
water. This, however, is determined by the cause of the kidney 
irritation. In general infection it may be well to give extra 
amounts of water, even at times by high enemas. 

Local congestion of the kidneys may be relieved by heat, 
applied as in body baking or by electric light baths, or by moist 
hot applications to the lumbar region. This is not with the 
object of causing elimination of toxins in uremic conditions, 
but with the object of relieving the congestion in the kidneys 
by dilating the systemic blood-vessels, especially the surface 
vessels. It should be emphasized that if there are edemas, 
either from kidney insufficiency or from cardiac insufficiency, 



I90 THE PRINCIPLES OF THERAPEUTICS 

the ingestion of water should not be pushed, in fact it may be 
well to diminish the intake of water. 

There is probably no such thing as a "sedative" diuretic; 
hence if the kidneys are inflamed, everything should be taken 
out of the diet and every drug omitted that carries or produces 
salts difficult for inflamed kidneys to excrete. In other words, 
so-called diuretic drugs should never be administered in acute 
and rarely in chronic nephritis. 

The amount of urine is increased by buchu, which is a mild 
stimulant to the kidney epithelium ; by caffeine, which raises the 
blood-pressure, stimulates the heart, and is also a mild stimulant 
to the kidney epithelium; by digitalis, which strengthens the 
heart and raises the blood-pressure; by scoparius, which stimu- 
lates the epithelium of the kidneys; by squill, which may raise 
the blood-pressure, and stimulates the kidney epithelium; by 
theobromine sodio-salicylate (diuretin) which slightly raises 
the blood-pressure and is a stimulant to the kidney epithelium. 

DRUGS USED TO RENDER THE URINE ALKALINE 

If the urine is very acid and irritates the bladder and urethra, 
as evidenced by an increased desire to urinate, with more or less 
pain, all food that increases the acidity of the urine should be 
withheld, a diet of milk and cereals given, plenty of water 
should be drunk, and no mineral acids should be taken. With 
this increased acidity of the urine there may be lumbar backache 
joint pains, and other signs of disturbances from uric acid. 

In this condition potassium or sodium citrate, given in doses 
of 2 grams, three times a day, directly after meals, combined 
with a modified diet, is effective treatment. The old "A. B. C." 
mixture, i.e., potassium acetate, potassium bicarbonate and 
potassium citrate, is a heritage used in the treatment of gonorrhea 
that may be buried without causing privation. The acetate 
and the bicarbonate are more disagreeable and no more efficient 
than the more pleasant citrate of potassium. 

If there is acute bladder or urethral inflammation, the potas- 
sium or sodium citrate should be pushed to the point of ren- 
dering the urine alkaline, ever though it is necessary to give a 
2-gram dose four or five times a day to accomplish this purpose. 



DRUGS TO RENDER THE URINE ALKALINE 191 

The urine, however, should not be allowed to be too long alka- 
line, as an alkaline urine tends, sooner or later, to irritate the 
mucous membrane of the bladder and cause more secretion of 
mucus ,with a tendency to alkaline deposits, and later, perhaps, 
ammoniacal fermentation and actual infection. Alkalies too 
long continued also debilitate the system rather than strengthen 
it, as they promote destructive metabolism. Consequently, 
alkalies are not tonics to weak, convalescent and neurasthenic 
patients. On the other hand, nervous patients are many times 
quieted with calcium salts, which, however, would rarely alka- 
lize the urine. 

Urine that is too acid or too long alkaline may allow deposits 
of salts and the formation of calculi; hence in either case the 
diet should be modified according to the condition. 

Potassium Citrate. — Potassium citrate occurs as transparent 
crystals or as a white powder, is very soluble in water,has rather 
of an unpleasant taste, and is well administered in peppermint, 
wintergreen, or cinnamon water. Although the Pharmacopce- 
ial dose is i Gm. (15 grains), in order to alkalize the urine gener- 
ally 2 Gm. (30 grains) must be given three or four times a day. 
The dose of 2 grams may be dissolved in 10 mils of a flavored 
water, and should be taken well diluted, best after meals, and 
on going to bed, if it is decided to give the drug four times a day. 
The official effervescing citrate of potassium is a pleasant method 
of administering this drug. The dose of this preparation is 4 
Gm. (1 drachm). An alkali given directly after meals more 
readily alkalizes the urine than when given at other times. 

Potassium citrate is not an antacid as far as the stomach is 
concerned. It is rapidly absorbed, tends to increase the alka- 
linity of the blood like all alkalies, somewhat lowers blood-pres- 
sure, and increases nitrogenous metabob'sm. 

As the potassium element is slightly depressant to the muscu- 
lar system, the sodium salts are sometimes preferable. Some 
indigestion may be caused by potassium citrate, but poisoning 
will not occur. 

Sodium Citrate. — Sodium citrate occurs in crystals or as a 
granular powder, has a saline taste, and is very soluble in water. 
The dose is the same, and the method of administration is the 



192 THE PRINCIPLES OF THERAPEUTICS 

same, and it is used for the same purposes as potassium citrate. 
The only advantage of the sodium salt is because sodium causes 
less muscle depression than potassium. 

DRUGS USED TO RENDER THE URINE ACID 

When the urine is too acid, meat, coffee and tea should be 
withheld, and the diet should be limited to carbohydrates and 
to vegetable proteins. On the other hand, when the urine is 
alkaline, meat should be allowed and dilute hydrochloric acid 
may be administered. In either condition more water should 
be taken to dilute the urine and therefore prevent deposits. 

An alkalinity of the urine may be temporary, due to drinking 
alkaline waters, or to a vegetable diet; or it may be due to 
some nervous disturbance, as shock or anxiety, or to actual 
disease of the brain. An alkaline urine deposits .the alkaline 
phosphates, and if this deposition long continues, phosphatic 
calculi may occur, and later fermentation. Except sometimes 
soon after meals the urine should not be alkaline, but should 
be acid. 

The diet should be modified to, if possible, render the urine 
acid. Nerve tire should be prevented, and, if necessary, a rest 
cure should be ordered. Although drugs cannot be guaranteed 
to render the urine acid, the most successful are dilute hydro- 
chloric acid and acid sodium phosphate. Salol, and all forms 
of salicylic acid, by causing salicyluric acid to appear in the 
urine, will more or less prevent fermentation in the bladder 
and may render the urine acid. Hexamethylenamina (uro- 
tropin), especially if given in conjunction with acid sodium 
phosphate, will generally succeed in rendering an alkaline 
urine acid. 

Sodium Triphosphate. — Acid sodium phosphate occurs as 
colorless crystals or white crystalline powder, has an acid taste, 
and is very soluble in water. The dose is 1 to 1.5 Gm. (15 to 
22 grains), given well diluted. It is well administered in syrup 
of citric acid and water. 

It is often advised that this drug be given in conjunction with 
hexamethylenamina when the urine is alkaline and an antisep- 



BACTERIA IN KIDNEYS AND BLADDER 1 93 

tic is desired, as hexamethylenamina will not act in alkaline 
media; but these two drugs, namely, acid sodium phosphate 
and hexamethylenamina, should not be combined in the same 
prescription, and should be administered at different times so 
that one drug is out of the stomach before the other enters it 
on account of chemical changes that may occur. 

This salt does not change in the stomach, but is converted in 
the intestine into disodium hydrogen phosphate. The acid 
phosphate in the intestine is neutralized by alkali drawn from 
the blood, and to offset this reduction of the alkalinity of the 
blood more acid is excreted in the urine. In large doses it has 
a laxative effect. 

DRUGS USED TO PREVENT THE GROWTH OF BACTERIA IN 
THE KIDNEYS AND BLADDER 

To meet this indication, namely, to destroy bacteria growing 
in some focus in the kidney, in the pelvis of the kidney, or in 
the bladder, no drug exeeds in value hexamethylenamina. This 
drug may not be tolerated in doses that are efficient, and salol 
or methylene blue may be substituted. Both are valuable. 
The oil of santal may also meet this indication, as, like many 
resins and aromatic oils and the turpentines, it is not only a 
stimulant to the genitourinary mucous membrane, but it is 
more or less of an antiseptic during its excretion, and germs do 
not well grow in urine carrying a considerable amount of santal. 

Alkaline urines tend to allow bacteria to grow, especially 
staphylococci; consequently, all alkaline urines must be made 
acid if possible, although colon bacilli will grow in both acid and 
alkaline urine. A bacilluria necessitates careful investigation as 
to its cause; also as to where the trouble lies, in the pelvis of 
the kidney, in the bladder, or in the urethra. Whatever treat- 
ment is needed, surgical or other, one of the urinary antiseptics 
is advisable. In acute conditions, with bacilluria, salol or 
hexamethylenamina are the best drugs, provided there is no 
inflammation of the kidneys. Methylene blue may also be 
used, and is not irritant. In chronic bacilluria santal oil is 
also of benefit. But, as just intimated, it is essential in every 

13 



194 THE PRINCIPLES OE THERAPEUTICS 

such condition that the diagnosis be made, and that surgical 
treatment be not too long delayed. 

All inflammations of the pelvis of the kidney, of the bladder, 
and of the urethra are surgical conditions and require local 
treatment. 

Hexamethylenamine . — Hexame thylenamine ( uro tropin) , a 
condensation product of ammonia and formaldehyde, occurs in 
colorless crystals or as a white powder, and is very soluble in 
water. The Pharmacopceial dose is 0.25 Gm. (4 grains); an 
effective dose as a urinary antiseptic is two or three times this 
amount. It is best given as a tablet or powder, dissolved in 
half a glass or more of water. It has been lauded for antiseptic 
and germicidal action in various parts of the body, but it has 
been shown that it cannot act as an antiseptic except in acid 
media {i.e., it cannot give up its formaldehyde except in the 
presence of acid), therefore it cannot act internally as an 
antiseptic except in the urinary tract when the urine is acid. 
A 0.25-gram dose may be administered several times a day, 
double that amount three or four times a day, or a gram (15 
grains) may be administered twice a day. In acute or chronic 
nephritis urotropin should not be administered, and in some 
individuals with normal kidneys it causes irritation, and in large 
doses may cause hematuria. Hexamethylenamina is sold 
under many proprietary names, and sometimes is combined 
with other drugs, but none apparently has any advantage over 
the official hexamethylenamina. This drug should not be 
given in any form for any great length of time, at least not 
without intermission. 

Methylthionine Chloride. — Methylene blue occurs as a dark 
green crystalline powder, is soluble in water and alcohol, and the 
dose is 0.10 Gm. (1% grains), in capsules, taken with plenty of 
water. It has been used as a genitourinary antiseptic in 
gonorrhea, in infections of the bladder and of the pelvis of the 
kidney. The drug may be administered every six hours, and, 
as just stated, should be always taken with plenty of water. 
Under its action the ur,ine becomes blue or blue-green. It has 
been used with some success in malarial fever when quinine 
cannot be given. 



EMMENAGOGUES I95 

This drug may cause nausea and vomiting, unless each dose is 
taken well diluted. If large doses have been given, it may cause 
backache, kidney and bladder irritation, and may even cause 
strangury and general depression. 

DRUGS USED TO STIMULATE THE MUCOUS MEMBRANES 

In chronic inflammation of the pelvis of the kidney, of the 
bladder and of the urethra, no one drug is more successful, in 
proper cases, than is santal oil. The more disagreeable copaiba, 
cubebs, corn silk, pichi, and numerous other lauded stimulant 
diuretics are no more efficient and generally not as favorable in 
their action as is the oil santal. 

Most of the drugs called stimulant diuretics stimulate the 
membrane of the genitourinary tract. All aromatic oils act in 
this manner, and these, as well as the drugs above mentioned 
modify the character of the urine and prevent the growth of 
germs, but they more or less disturb the digestion. 

Oil of Santal. — Oil of sandalwood is a volatile oil distilled 
from sandalwood, and occurs as a pale yellow, somewhat thick 
liquid having a strong odor and taste of sandalwood. It is 
best administered in flexible capsules containing 0.30 to 0.60 
mils (5 to 10 minims), given three or four times a day, best 
after meals ; or, if taken on an empty stomach, plenty of water 
should be drunk at the same time. 

Santal oil gives its odor to the urine and to the breath. 
Large doses, and even small doses sometimes, cause backache in 
the lumbar region and pain down the ureters sometimes into the 
testicles. It not only acts as an antseptic in the urinary pas- 
sages, but many times seems to stimulate a chronic inflammation 
to more rapid healing. It should not be used in acute inflam- 
matory conditions. 

Santal oil has also been used as an expectorant to promote 

more active secretion in bronchitis, when the exudate is thick 

and tenacious. 

EMMENAGOGUES 

Before giving so-called emmenagogues, the cause of the 
amenorrhea must be sought and pregnancy must be excluded. 
If the cause of the amenorrhea is systemic, the underlying con- 



196 THE PRINCIPLES OF THERAPEUTICS 

dition must be treated. If there is anemia, proper diet and 
iron is the treatment. Amenorrhea is often due to endocrine 
gland disturbances, and a frequent cause is insufficiency of the 
thyroid. Thyroid feeding, ovarian feeding, and the adminis- 
tration of corpus luteum are all often efficient treatments. If 
there is dysmenorrhea, a local cause should be sought and, if 
found, treated. 

In the many preparations, Pharmacopceial, National For- 
mulary, proprietary mixtures, and nostrums recommended for 
dysmenorrhea, the efficient ingredient is generally alcohol. The 
dose of each of these alcoholic preparations recommended is 
generally sufficient to cause alcoholic relaxation, and therefore 
a diminution of the pain. 

In proper cases, the most efficient emmenagogues are thyroid, 
ovarian, and corpus luteum extracts. The use of these pre- 
parations in amenorrhea will be described in Part IV. If 
the patient is anemic, iron is a most valuable emmenagogue. 
Many times precipitated manganese dioxide in doses of 0.10 to 
0.20 Gm, (about 2 or 3 grains), best given in capsule, is efficient 
in hastening menstruation or causing a scanty menstruation to 
become more profuse. It should be given for several days 
before the expected flow. 

OXYTOCICS 

Different terms have been applied to these drugs. The term 
"oxytocic" should be limited to those drugs that have the 
power to hasten parturition. The term "ecbolic" has been 
applied to drugs which not only increase the rapidity of natural 
parturition, but which may cause such contraction of the uterus 
as to cause abortion. Such drugs have also been termed 
"abortifacients." Some drugs that cause contraction of a 
dilated uterus cannot produce abortion. 

If the uterus is unduly dilated after parturition, ergot will 
generally cause contraction of the uterus, often, however, 
interfering with desirable after pains which are necessary for the 
uterus to evacuate clots, etc. If chloroform has been adminis- 
tered during the parturition, an oxytocic is generally indicated, 
unless an assistant can sit at the bedside and clasp the uterus 



OXYTOCICS 197 

through the abdomen until it normally contracts. If there 
is post-partum hemorrhage, besides the drug treatment (ergot 
and pituitary extract) local measures are needed, as the intro- 
duction of ice into the uterus; or the reverse, namely, very hot 
water introduced into the uterus. 

For a dilated uterus at other times than post-partum, and 
when there is profuse bleeding, hydrastinine is of value, as is 
also quinine. Ergot frequently acts well in stopping profuse 
menstruation. For too frequent and too profuse uterine flow, 
especially in young girls, mammary extract is of value. It 
should be urged that drugs that contract the uterus are used 
symptomatically, and the cause of the increased uterine flow 
must be diagnosed and properly treated. 

Mammary extract, in the form of tablets, given two, three or 
four times a day, beginning with the fourth or fifth day of the 
menstruation will frequently stop the flow in a normal manner, 
while ergot will cause sudden stoppage, with pain, and often 
to the disadvantage of the patient. In too frequent menstrua- 
tion, if mammary extract, one or two tablets a day, is given for 
at least a week before the date at which the menstruation has 
been coming, it may postpone the menstruation to the normal 
period. 

There is no question that ergot will generally slow any uterine 
flow, but it has the disadvantage of stopping the flow too soon 
and producing nausea in many patients. It also often raises 
the general blood-pressure, but not always. It should not be 
used after parturition as a routine practice, as it may cause 
contraction of the lower part of the uterus and thus shut up in 
the uterus blood clots and membrane, and it should rarely be 
used before the third stage of labor has been completed. 

Quinine sulphate has often been used to cause a better tone of 
the uterus after parturition, and to expel blood clots. It will 
also, in good sized doses, cause contraction of the uterus in pro- 
fuse menstruation, unless there is some more serious condition 
than simple dilatation present. 

Pituitary extracts, namely, the blood-pressure-raising stuff 
from the posterior lobe of the hypophysis, best given hypo- 
dermatically, is of value (when used with care) in certain 



1 98 THE PRINCIPLES OF THERAPEUTICS 

conditions during parturition as an oxytocic. This drug 
always, by the way, raises the blood-pressure and stimulates the 
heart. 

Hydrastinine Hydrochloride. — Hydrastinine is obtained by 
the oxidation of hydrastine, and the hydrochloride occurs as 
light yellowish needles or as a powder, and is very soluble in 
water and alcohol. This preparation is more active than 
HydrastincB Hydrochloridunij as a uterine contractor, hence the 
latter is not needed. This drug raises the blood-pressure, 
generally slows the heart, and sometimes causes depression. 
The dose by the mouth is 0.03 Gm. (}-£ grain), but it is often 
given hypodermatically. It may be given in all conditions of 
bleeding from the uterus, but it is not sufficiently active for the 
treatment of post-partum hemorrhage. 

SECOND DIVISION 

CLASS III 

Drugs Used for Action on the Respiratory Tract 

As these drugs are generally used to prevent or treat colds 
and coughs, it is not amiss to briefly discuss the causes of colds 
to better understand their prevention, and to discuss the types 
of cough to better direct their treatment. Such a discussion is 
of special value, as too much faith has long been placed in the 
ability of the drugs of this class to prevent and cure disease of 
the air passages. 

Colds due to adenoids, tonsil disease, nasal obstruction, sinus 
disease, tooth infection, too much or too little clothing, too 
much or too little bathing, poorly ventilated bedrooms, the 
inhalation of dust especially irritant dust, carelessness in using 
germ contaminated telephones, carelessness in using handker- 
chiefs and towels that have been infected by others, and the in- 
halation of droplets of infection sneezed or coughed into the 
atmosphere by those who are infected, cannot often be pre- 
vented by drugs. 

Coughs due to reflex irritation, and coughs due to local irri- 
tation, such as congestion of the lingual tonsil, cannot be cured 



DRUGS FOR ACTION ON RESPIRATORY TRACT 1 99 

by so-called expectorants any more than can coughs due to 
cardiac insufficiency be cured by this class of drugs. The type 
of cough must be noted and the probable cause must be found 
before success from medication can be expected. 

Cough may be caused by irritation in any part of the respira- 
tory tract, may be caused by a disturbance of the stomach act- 
ing rerlexly through the pneumogastric nerve, and may be 
caused by reflexes from the nose and from the ear. Cough may 
also be caused by passive congestions, venous congestions, in 
some part of the air passages caused by an insufficient heart or 
by a valvular lesion. Any irritant in the bronchial tubes, tra- 
chea, and larynx will cause a cough. A tuberculous or other 
abnormal process in the lungs may so irritate the nerves as to 
cause coughing, and congestions in any part of the lung and in 
the pleura will cause more or less coughing. 

Very frequently when there is no congestion of the bronchial 
tubes, trachea, or larynx, and therefore no abnormal exudate, 
the cough is dry and non-productive. Such coughing is of no 
advantage to the patient, is very tiresome and irritating to the 
mucous membranes, and may even cause erosions and bleeding 
from some part of the laryngeal region, or just below or just 
above it. Such slight hemorrhages are often diagnosed as an 
hemoptysis and as indicative of tuberculosis. 

The dry cough of incipient tuberculosis is a mild, hacking 
cough. The cough from cardiac dyspnea, or from anything 
that congests the venous vessels of the respiratory tract, is 
short and more or less gentle. The cough due to a laryngeal 
tickle, or to a lingual tonsil tickle, or to the rarer elongated 
uvula tickle is a loud cough, generally coming in series or in 
showers. If the lingual tonsil is the part at fault, the coughing 
continues until something soothing has quieted this region, or 
until the part has been actually scraped with the rush of air, 
similar to scratching until it bleeds some itching spot on the sur- 
face of the body. The first stage cough of a bronchitis is also 
dry and may be harsh, and in plethoric, strong individuals is very 
sturdy and strenuous. With bronchial exudate, and in the 
moist stages of tuberculosis, and in the second stage of pneu- 
monia, the cough is productive and less harsh, although if, in 



200 THE PRINCIPLES OE THERAPEUTICS 

bronchitis, only the larger tubes are affected, a series of coughs 
may be necessary to bring the secretion to the mouth for expec- 
toration. A dry trachea may give a troublesome cough, which 
is difficult to stop, as repair of the epithelium takes place but 
slowly in the trachea. The cough of pleurisy is a dry, non-pro- 
ductive, repressed cough, as every movement causes pain. The 
asthmatic cough is wheezy, and continues until frothy mucus 
is expectorated, and there is more or less difficulty of inspiration. 
The cough of pertussis occurs in spasms, with difficulty in in- 
spiration, hence the whoop. In whooping cough, and in patients 
with asthma, emphysema of the upper parts of the lungs may 
occur from the effort to cough and expire against a more or less 
closed glottis. The cough of a laryngitis is husky, and the 
voice is generally hoarse at the same time. Pain in the sides in 
the region of the diaphragm insertions, and epigastric pain, as 
well as pains in other parts of the chest, shoulders, and neck, 
may occur from hard coughing. 

It is obvious that before drugs are given to stop a cough, or 
for expectorant action, the diagnosis of the cause of the cough 
must be made. Cough mixtures are too frequently given, to 
the disturbance of the stomach, when the cause of the cough 
cannot be removed by such treatment. Inflamed, dry mucous 
membrane in the air passages requires treatment that will pro- 
mote secretion. The secretion of these membranes will be in- 
creased by ipecac, by small doses of ammonium chloride, by 
inhalation of steam and vaporized drugs, and, in subacute or 
chronic conditions, by iodides. 

Too profuse secretion requires treatment to diminish it, 
perhaps by atropine, or by large doses of ammonium chloride, 
or by terpin hydrate. Nauseating, sweet, syrupy mixtures 
that upset the stomach are not justifiable. Codeine, or other 
sedatives, may be needed to diminish the frequency of a 
cough, as it is evident that, even in bronchitis, with a cough 
that is very frequent and non-productive, coughing does harm 
and is not of benefit. If a cough is due to spasm, as in asthma, 
drugs that change the character of the circulation and relax 
muscle spasm are required. 

Inflammation in the nose, throat, larynx and trachea may be 



EXPECTORANTS 201 

treated by inhalations, sprays, douches, and by gargling. Re- 
moval of obstructive adenoids and of diseased tonsils is fre- 
quently the only curative treatment of nose, throat and ear 
disturbances. 

DRUGS USED TO INCREASE THE SECRETION OF THE MUCOUS 
MEMBRANES.— SO-CALLED EXPECTORANTS 

It should be noted that any drug that will act on the mucous 
membrane of the bronchial tubes will also act on the mucous 
membranes of all the air passages, and also more or less on all 
the mucous membranes of the body. It should be recognized 
that general systemic treatment to modify the congestion and 
circulation in the lungs is of more importance than is a so- 
called expectorant. Various physical therapies can do more 
toward aborting and stopping a cold than can drugs. 

The best drug to promote secretion of the air passages in 
acute conditions is ipecac in frequent doses, not sufficient in 
amount to cause nausea; small doses of ammonium chloride 
are also efficient for this purpose. Inhalations of warm, moist 
air in dry conditions of the upper air passages are beneficial, 
and a sedative, as codeine, to allay the cough, is of value. 
There is no excuse for using the irritating and nauseating am- 
monium carbonate, or any ammonium preparation other than 
ammonium chloride. If a codeine, or other, preparation that 
tends to dry up secretion is used too long, the membrane be- 
comes dry and the cough is protracted. There is no activity 
of heroin (diacetylmorphine) that codeine does not have, and 
the tendency of heroin to cause a pernicious habit should pre- 
clude its use in medicine. It is not a respiratory stimulant. 

In chronic dry conditions of the air passages an iodide is 
almost a specific; the dose need not be large. 

Ammonium Chloride. — Administration. — Ammonium chlo- 
ride (muriate of ammonium) occurs as a white crystalline 
powder, has a disagreeable nauseating saline taste, and is 
soluble in water. The dose varies from 0.25 Gm. to 1 Gm. 
(4 to 15 grains). It should always be administered in solution, 
and best in a sour mixture. Sweet syrups prolong the taste 
and increase its unpleasantness, although a small dose for a 
child may be disguised by a syrup, such as syrup of tolu or 



202 THE PRINCIPLES OF THERAPEUTICS 

syrup of wild cherry. Plenty of water should always be taken 
with, or after, a dose of this drug. 

Nascent ammonium chloride may be inhaled from various 
simple apparatus which will combine the fumes of strong am- 
monia water and hydrochloric acid. Ammonium chloride is 
thus formed in white clouds which may be inhaled, and is 
apparently of benefit in acute colds and laryngitis. 

The official Trochisci Ammonii Chloridi do not represent a 
good method of administering ammonium chloride. These 
troches are supposed to be dissolved in the mouth. Each 
troche contains i}^ grains of ammonium chloride. 

Action. — Large doses of ammonium chloride, or when it is 
given not well diluted on an empty stomach, may cause irrita- 
tion, as well as nausea from its taste. It is quickly absorbed, 
and seems to have a specific action on mucous membranes, 
increasing their secretion, and it is especially active in stimulat- 
ing secretion of the mucous membranes of the respiratory tract. 
It has no important action on the nervous or circulatory systems. 
It is excreted by the kidneys, by the mucous membranes of the 
respiratory and digestive organs, and by the salivary glands. 
It is not poisonous, and therefore has no over- action except that 
it may cause sufficient nausea to interfere with digestion, but 
it rarely has this undesired action unless the dose is large. 

Uses. — Ammonium chloride is rarely used except as an 
expectorant, i.e., to promote the secretions of the air passages. 
Its most efficient action is in the treatment of acute and sub- 
acute bronchitis. If the cough is excessive and non-productive, 
ammonium chloride is well combined in small doses with code- 
ine. For this purpose it is repeated frequently: 

Codeine sulphate o . 20 Gm. 

Ammonium chloride 5 . Gm. 

Syrup of citric acid 25 . mils 

Water up to 100 . mils 

Mix. 

Sign : A teaspoonful, in water, every two or three hours. 

It is well to take a good drink of water after the medicine. 
If the cough is not troublesome, the codeine may be omitted. 



EXPECTORANTS 203 

Such a prescription may be used in the acute stages of colds 
and bronchitis when the secretion is not sufficient for comfort. 

If the secretion is profuse and semi-purulent, larger doses of 
ammonium chloride should be given, less frequently, as 0.40 or 
0.50 Gm. about (6 to 7^ grains) three times a day. 

Ammonium chloride may be used in catarrhal jaundice, or in 
conditions of other mucous membranes that require some stimu- 
lant that will cause the mucus secreted to be less tenacious, and 
therefore to be more easily passed along the tubes that are in- 
flamed. Large doses, as 0.50 to 1 Gm. (7^ to 15 grains) have 
been given with apparent success in hastening the reduction in 
size of a spleen enlarged by malarial poisoning. 

Ipecac. — Administration. — Ipecac is official as the dried root, 
and is used as such in powdered form for emetic action. The 
dose as an emetic is 1 to 2 Gm. of the powder. The official 
preparations are the Fluidextract, the Syrup which is made 
from the fluidextract in the strength of 7 per cent, of the 
fluidextract, and Pulvis Ipecacuanha et Opii (Dover's powder). 
This preparation contains 10 per cent, of ipecac. The expecto- 
rant dose of the fluidextract is 0.05 mils (or 1 minim). The 
Pharmacopceial expectorant dose of the syrup is 1 mil (15 
minims) . If this dose is to be repeated, it is too large, as it will 
cause nausea and vomiting; the best action of the syrup of 
ipecac as an expectorant is in very small doses frequently re- 
peated. The dose for this purpose, then, should not be more 
than from 0.25 to 0.50 mil (4 to 7^ minims), given every two 
hours. 

The alkaloid Emetince Eydrochloridum, (emetine hydrochlo- 
ride) occurs as a whitish crystalline powder, which is soluble 
in water. This preparation is principally used hypodermat- 
ically in doses of 0.02 Gm. (J4$ grain). It is a specific treatment 
for amebic dysentery. 

Ipecac contains another alkaloid, cephaelin. To this alkaloid 
the drug owes its emetic action, the alkaloid emetine not acting 
as an emetic. 

Action. — Ipecac causes vomiting mostly by its local irritant 
action in the stomach, although after absorption it acts on the 
vomiting center. Both ipecac and its alkaloid emetine are 



204 THE PRINCIPLES OF THERAPEUTICS 

irritant to the skin and mucous membranes, the merest whiff 
of ipecac causing some individuals to sneeze and have symptoms 
of hay fever and even asthma. Ipecac is rapidly absorbed, and 
promotes the secretion of the glands of the mucous membranes 
and of the salivary glands. The drug and its alkaloid emetine 
are eliminated to some extent through the intestinal walls, and 
during such elimination kill the amebae which may be harbored 
there in amebic dysentery. In combination with opium in the 
Dover's powder it promotes perspiration. 

Over-action. — The most frequent symptom of over-action of 
ipecac is, of course, nausea and vomiting, and it may also irri- 
tate the intestines and cause diarrhea. Large doses of emetine 
have caused paralysis, prostration, and even fatal cardiac fail- 
ure. Some individuals who are very susceptible to the action 
of ipecac when taken internally, have an eruption on the skin, 
erythematous or urticarial in type. 

Treatment of Poisoning. — The treatment of poisoning, if such 
should occur, is evacuation of the stomach and bowels, the hypo- 
dermatic administration of morphine to stop the vomiting, and 
atropine and strychnine, hypodermatically, to overcome any 
depression that may be present. 

Uses. — The principal use of ipecac is as an emetic, and the 
best dose of the powdered ipecac for this purpose is 2 Gm,. (30 
grains). If the syrup of ipecac is used, the dose for an adult is 1 
or 2 tablespoonfuls. 

As above outlined, a valuable use of ipecac is to cause increased 
secretion of dry mucous membranes, thus diminishing their 
congestion. As soon as the mucous membranes of the air pas- 
sages secrete freely , distress is diminished, obstructive swelling is 
reduced, and if the bronchial tubes are affected, coughing be- 
comes easier and the secretion is more easily expectorated. 

The use of emetine in amebic dysentery has already been 
described; see page 181. It has also been stated that emetine 
bismuth iodide is perhaps the best preparation to give by the 
mouth for the treatment of that disease. This preparation is 
not official. 

Emetine, either used locally or given by injection, destroys 
the ameba which occurs in pyorrhea alveolaris, but as it does 



DRUGS TO DECREASE SECRETION OF MUCOUS MEMBRANES 205 

not destroy the more important pathologic germs always asso- 
ciated with the endameba, and as it has not been shown that the 
endameba has any pathogenic importance, the much lauded 
emetine treatment of pyorrhea alveolaris becomes of little 
importance. 

DRUGS USED TO DECREASE THE SECRETION OF THE MUCOUS 

MEMBRANES 

Ammonium chloride in medium sized doses is often successful 
in hurrying an inflammation of a mucous membrane back to 
health. Terpin hydrate is another very useful drug for this 
purpose. Morphine and codeine will not only act as sedatives 
in irritated conditions of the mucous membranes of the upper air 
passages, but they also tend to dry the mucous membranes, 
often more than is desired. Atropine dries the nose, throat, 
and bronchial tubes, much as it inhibits most other secretions. 
Atropine is rarely advisable except as an abortive treatment 
for colds, when it may be given in small doses, frequently 
repeated (as }ioo of a grain of atropine sulphate every three 
hours for ten doses), and in such profuse bronchorrhea as 
would occur in the undesirable action of pilocarpine. 

Many of the balsams and aromatic oils, either inhaled or 
administered by the mouth, often tend to diminish the secretion 
of the air passages. 

The best treatment in continued colds and continued simple 
bronchitis is often by tonics, as represented by the following 
prescription : 

Quinine sulphate 2 . Gm. 

Reduced iron . 1 . Gm. 

Strychnine sulphate o . 03 Gm. 

Mix. 

Make 20 capsules (dry). 

Take a capsule three times a day, after meals. 

The above tonic capsule is a suggestion, but any tonic treat- 
ment is of value. The hypophosphites are absolutely of no 
value, and the only reason that a hypophosphite preparation 
does good is because it is combined with quinine, strychnine 
and iron. 



206 THE PRINCIPLES OF THERAPEUTICS 

Cod-liver oil may be a very valuable treatment in certain 
conditions of prolonged bronchitis; when the circulation is 
impaired, digitalis is of benefit. 

Change of climate to a drier air and especially to an atmos- 
phere of pine woods, is often advisable, even when no serious 
trouble with the lungs is suspected. Prolonged colds and 
coughs, and recurrent colds and coughs, should be considered 
as possible precursors of tuberculosis and treated accordingly. 

There is absolutely no need for, and no value in, all of the 
many old so-called expectorants, cough syrups and cough 
mixtures. The drugs mentioned above are sufficient for the 
treatment of bronchitis. 

At times a prolonged cough with expectoration may be well 
treated by small doses of sodium iodide, which seems to promote 
healing. An iodide is especially indicated when there is an 
asthmatic condition with the bronchitis. 

Terpin Hydrate. — Terpin hydrate occurs as colorless prisms, 

which are slightly bitter in taste and practically insoluble in 

water. It is non-irritant and non-poisonous in all ordinary 

doses. It is best administered in powder, in capsules, or as 

tablets to be crushed with the teeth before swallowing. The 

dose is about 0.30 Gm. (5 grains), taken with plenty of water, 

three, four, or five times a day. This drug tends to dry up 

secretions of the air passages, and does not interfere with the 

appetite or irritate the stomach in any way. Tablets of terpin 

hydrate in combination with heroin are very frequently ordered, 

and have been extensively used, but it is best not to administer 

heroin. If a sedative is required, codeine is better; heroin is 

not needed. 

DRUGS USED TO RELAX SPASM 

Contractions of parts of the air passages occur in asthma 
and in croup. In spasmodic croup an emetic such as the syrup 
of ipecac is indicated, with inhalations of steam and hot moist 
applications to the neck. 

Asthma is a frequent and very troublesome condition, and 
an asthmatic attack requires treatment by one of the drugs 
suggested in this classification. An asthmatic condition may be 
due to a chronic disturbance as emphysema, and it may be due 



DRUGS USED FOR ACTION ON CIRCULATION 207 

to an insufficient heart. The blood-pressure may be too high 
or may be too low, and proper treatment, in the first instance to 
reduce the blood-pressure, and in the second instance to increase 
the strength of the heart, will tend to remove the asthmatic 
condition. 

Many times the best treatment of acute asthma is by nitro- 
glycerin in doses of }{ 00 of a grain, dissolved on the tongue, 
and repeated in fifteen minutes, if relief is not obtained. When 
frontal headache is caused by this drug the spasm of the 
bronchial tubes will be relaxed. If there is considerable venous 
congestion and the heart is laboring and insufficient, suprarenal 
preparations given for absorption in the mouth, either as 5 to 10 
drops of adrenalin solution (1-1000), or as a suprarenal tablet 
dissolved in the mouth, will be useful. 

Various substances to be burned and the fumes inhaled, or to 
be smoked, all containing atropine in some form, most fre- 
quently as stramonium leaves, and most of them containing a 
nitrite (generally the nitrate of potassium) tend to relax spasm 
and cause relief. It is probable that atropine sulphate in- 
jected hypodermatically will act as well as the inhaled fumes of 
stramonium leaves. The slower acting but often effective 
bromides and chloral may be administered, provided the circu- 
lation is good. 

Morphine should be given only in exceptional cases and when 
the indication is urgent. Many an asthmatic patient has be- 
come addicted to the use of morphine, and the physician 
cannot be too careful lest he cause such a habit. 

CLASS IV 
Drugs Used For Action on the Circulation 

The care of the heart and circulation becomes of more im- 
portance every year, as we have developed a condition of 
nervous tension, and the circulation is easily thrown out of 
balance. The advance of civilization has weakened the circu- 
latory power as evidenced during the ages, first by patients 
surviving most terrible bleedings; then vomitings; then purg- 
ings; then the use of aconite; then the use of alcohol as a " stimu- 



2oS THE PRINCIPLES OE THERAPEUTICS 

lant;" then the use of coal-tar drugs to combat fever; and 
then the starvation era. Next came the recent strychnine 
age; and now we have reached the digitalis age, and each, in 
its era, was considered the proper treatment of serious illness. 
This chronological story shows that the reserve strength of the 
heart has grown less and less, and it is the reserve strength of 
the heart upon which the individual must depend in emergencies. 
The following are some of the reasons for the progressive 
circulatory insufficiency, and especially for the lack of reserve 
strength of the heart at the present time: 

i. Less sleep than is necessary for rest of the brain and heart. 

2. More excitement: rapid travel, constant dangers, more 
evening amusements, bright lights, more noise, more calls on 
one's attention, and the need for rapid execution of duties. 

3. A large assortment of rich foods that cause, sooner or later, 
substances to be produced and absorbed that are irritant to 
the brain or depressant to the heart, or that cause high tension. 

4. Too much tea and coffee. 

5. Too much tobacco. 

6. Strenuosity needed to keep up with the times. 

7. Strenuosity not needed, but assumed: too much com- 
petitive athletics, too much dancing, too much misdirected 
exercise by those who are not in condition for it. 

8. Business and household frets of the age. 

9. Impatience with, and unwillingness to stand, even a 
little pain, and the consequent taking of depressant analgesic 
drugs, especially the coal-tar and synthetic drugs. 

10. Mouth infection, and consequent endocrine gland dis- 
turbance. 

These are probably not all of the causes of the weakened 
hearts of this age, but be the causes what they may, the physi- 
cian's primary duty to-day, with every illness and with every 
operation, is to care for the heart. The blood-pressure must 
be watched; the anesthesia must be short; even nerves must 
be blocked to relieve shock; strychnine, atropine, caffeine, 
camphor, epinephrine and pituitary stimulation may have to be 
given; transfusion may be required; and, now, even purging 



DRUGS USED FOE. ACTION ON THE CIRCULATION 200, 

before operations is being abolished. This all shows the weak- 
ened circulations, and the lack of reserve heart strength, that 
are being encountered. In other words, the cardiac reserve is 
not there, and cannot be depended upon, therefore the im- 
portance of a good understanding of the drugs of this class, as 
they not only can save life, but also they are often misused. 

The nutrition of the heart muscle is derived from the blood 
supplied to it through the coronary arteries. The activity 
of the circulation of the blood through these vessels and con- 
sequently the amount of nutrition furnished to the heart 
muscle depends upon the blood-pressure in the aorta during 
the cardiac diastole, and also upon the complete relaxation of 
the cardiac muscle during diastole. Drugs which increase the 
strength of the cardiac systole or which increase arterial tension 
increase the blood-pressure in the aorta, and consequently 
increase the activity of the circulation in the coronary arteries, 
and therefore improve the nutrition of the heart. Only such 
drugs as meet these requirements can be cardiac tonics, and 
these drugs act slowly and cause the best results only after a 
more or less prolonged use. 

To meet the condition of shock or heart failure or any sudden 
cardiac weakness, drugs which are stimulant to the heart and 
vasomotor system are indicated. It is a question of momen- 
tary emergency and not a question of cardiac nutrition. 

It is impossible to advise what drug or drugs should be used 
in a given case, but the following suggestions of the special circula- 
tory activities of the drugs named in the classification may indi- 
cate when they should be used: 

Atropine causes increased rapidity of the heart, raises the 
blood-pressure, and awakens the brain and nerve centers. Its 
activities last for some time; it is slow of excretion; and the 
average dose of the sulphate is Koo °f a grain. Undesired 
effects from this drug are flushing of the face, nervous ex- 
citement, insomnia, dryness of the throat and skin, and 
tachycardia. 

Camphor causes an increased rapidity of the heart, dilates the 
peripheral blood-vessels, thus relieving internal congestions and 
giving a feeling of warmth and well-being, and slightly stimu- 

14 






2IO THE PRINCIPLES OF THERAPEUTICS 

lates the nervous centers. It acts quickly, and its action is soon 
over, hence it may be frequently repeated, every hour in small 
doses. Generally it is best given intramuscularly in a saturated 
solution in a sterile vegetable oil (tumors have been caused by 
injections of camphor and petroleum oil), in a dose of 0.20 Gm. 
(3 grains), which is the .strength of camphor in the ampules 
which may be obtained for such medication. 

Caffeine causes the heart to become more rapid and its con- 
tractions stronger, raises the blood-pressure, stimulates the brain, 
and increases the output of urine. It may be administered 
as a cup of strong coffee, or as citrated caffeine in the dose of 
0.30 Gm. (5 grains), or hypodermatically in the form of caf- 
feine sodio-benzoate in a 0.20 Gm. (3 grains) dose. It acts 
quickly, may be repeated in two or three hours, and is more or 
less rapidly excreted. It may cause prolonged insomnia and, 
rarely, tachycardia. 

Strychnine stimulates all the nerve centers, may slow the 
heart, often makes its contractions stronger, and at times 
raises the blood-pressure and increases the output of urine. It 
often prevents sleep, and if too frequently administered or given 
in too large doses, may cause the heart to become rapid and 
prevent complete diastole, due to over-stimulation. Strychnine 
is used too much in cardiac depression, although when the heart 
fails and the vital nerve centers are sluggish strychnine may 
greatly improve the condition and perhaps save life. In shock 
other drugs are better. The dose of strychnine sulphate in 
emergencies is }£q to 3^0 of a grain, given hypodermatically. 

Digitalis, given intramuscularly, will help a weak heart in 
from four to twelve hours, but its full action will not take place 
until from eighteen to twenty-four hours. With a weak heart 
very large doses should not be given, as excretion is slow and 
poisoning readily occurs. Also large doses should not be given if 
the patient is already more or less saturated with the drug. It 
cannot act in a short time unless it is administered intravenously 
hence it is not a drug for emergencies. It should not be given 
when the heart is very slow, or in heart failure when the patient 
has for some time had a serious feverish disease. It should not 
be given when there is acute myocarditis or acute endocarditis, 



. DRUGS TO ACCELERATE THE HEART 211 

or if these conditions are suspected. It may be used, if indi- 
cated, early in acute disease or in broken compensation in chronic 
heart disease. It is not indicated in acute heart failure or 
shock. It slows the heart, strengthens its contractions, gener- 
ally raises the blood-pressure (it may lower a high pressure if 
there is cardiac dilatation), and increases the output of urine. 
If too large or too frequent doses are given, the heart may be- 
come fast, headache is present, a diminished amount of urine is 
passed, vomiting is frequent, and diarrhea may occur. It 
should not be administered too often, generally best twice in 
twenty-four hours. As stated, it is of no value in sudden 
emergencies, but in the slower emergency of auricular fibrillation 
it is the drug to use, and in good sized doses. 

Strophanthin given intramuscularly or intravenously is of 
great value in heart failure in severe illness. It should be given 
in one sufficient dose, not ordinarily to be repeated, and should 
not be given after a patient is under the influence of digitalis. 
Ampules for intramuscular or intravenous administration may 
be obtained. It should be noted that the solution in these am- 
pules should be neutral or slightly acid ; if it is alkaline the drug 
has deteriorated. 

Pituitary Extracts made from the posterior lobe of the 
hypophysis raise the blood-pressure and strengthen the heart; 
they are best given hypodermatically, and ampules may be 
obtained for this purpose. 

Suprarenal Extracts or epinephrine preparations raise the 
blood-pressure both when given on the tongue for absorption 
in the mouth, or when given hypodermatically. 

Ergot, when an assayed fluidex tract is used and it is given 
intramuscularly, raises the blood-pressure. The dose is i or 2 
mils, injected deeply into the deltoid muscle, and it may be 
repeated two or three times in twenty-four hours, if needed. 

DRUGS USED TO ACCELERATE THE HEART 

The drugs used for this purpose are atropine, camphor, 
caffeine, and strychnine. As all of these drugs act more or less 
on the nervous system, they are better described under that 
class. 



212 THE PRINCIPLES OF THERAPEUTICS 

DRUGS USED TO DEPRESS THE HEART 

Most methods employed to depress the heart, once used so 
much in the first stage of acute disease, should be dropped, 
owing to the danger of precipitating cardiac weakness. Even 
the milder methods of causing slowing of the heart and lowering 
of the blood-pressure, in the beginning of an illness, by means 
of aconite or of veratrum viride are now but little used. Fortu- 
nately or unfortunately (because they are too much used) the 
coal-tar products, as acetanilid, phenacetin and antipyrin, and 
some synthetics as aspirin, not only lower the temperature 
and stop aches and pains, but also lower the blood-pressure 
and depress the heart. They are often used to accomplish all 
these results at once. 

Aconite. — Administration. — Aconite (monkshood) is not used 
as such, and is best administered in the form of the official 
tincture, which contains 10 per cent, of the drug. The official 
dose of 0.3 mils (5 minims) is too large, if it is to be repeated. 
The best method of giving aconite to cause slowing of the pulse 
and lowering of the blood-pressure is to administer a drop 
every half hour until the effect desired is produced, and then to 
stop it. 

Aconitine, the alkaloid of aconite is very poisonous, and 
should not often be used. The dose is 0.00015 Gm. (Moo of a 
grain). 

Action. — This drug acts rapidly to slow the heart and lower 
the blood-pressure, and it somewhat dilates the peripheral blood- 
vessels and lowers temperature. It is excreted in the urine. 

Over-action. — It may cause tingling of the tongue, tingling 
and numbness of the extremities, and a feeling of faintness. 

Toxic Action. — It causes death by depression of the respira- 
tory center and the heart. 

Treatment of Poisoning. — Further absorption of the drug must 
be prevented by emetics; there must be absolute rest; dry heat 
applied; and respiratory and circulatory stimulants given. 

Uses. — 1. To reduce fever. For this object one drop of the 
tincture may be given every half hour until the pulse shows a 
distinct slowing and softening; it should then be stopped. 



DRUGS TO DEPRESS THE HEART 213 

Aconite is not now much used to meet this indication, as the 
coal-tar drugs are more efficient in reducing temperature and 
promoting sweating, and at the same time they depress the 
heart and circulation. 

2. To lower the pressure in hypertension. It is not often 
advisable to use aconite for this purpose, as hypertension is 
continuous, and the continuous use of aconite is inadvisable, 
on account of its weakening the heart muscle. 

3. To allay peripheral pain. It is rarely advisable to use 
aconite for this purpose, although in full doses it will benumb 
the peripheral nerves, but at the same time it causes depression. 
Any local application of aconite is inadvisable. 

Veratrum Viride. — Administration. — Veratrum viride (green 
hellebore, American hellebore) is not used as such, but in the 
form of the official nuidextract, the dose of which is o.i mil 
(ij^ minims), or as the official tincture, which represents 10 
per cent, of the drug, in the dose of 0.5 mil (7^ minims). 
When these preparations are used to lower the blood-pressure 
and slow the heart, they should be used as it is advised to use 
aconite, namely, about 2 or 3 drops of the tincture every half 
hour until the results desired are obtained. 

Action. — This drug is more or less of a cardiac depressant 
(not as depressant as aconite) , slows the pulse, lowers the blood- 
pressure, and lowers the temperature. 

Over-action. — It causes vomiting so soon that when adminis- 
tered by the mouth serious poisoning is not likely to occur. 
The treatment of its over-action is to wash out the stomach, 
administer atropine and digitalis, keep the patient quiet, and 
surround him with dry heat. 

Uses. — The only use for viratrum viride is to slow the heart 
and lower the blood-pressure. It is much less likely to cause 
cardiac depression than is aconite, but is less efficient, at least 
in the doses generally used. Perhaps this drug should be used 
more frequently and in larger doses (provided the stomach is not 
irritable, as it is likely to cause vomiting) ; however, as already 
stated in the case of aconite, this drug also has given place to 
the coal-tar drugs. 

Veratrum viride has been suggested for chronic hypertension. 



214 THE PRINCIPLES OF THERAPEUTICS 

It is doubtful, however, if it should be used for this purpose any 
great length of time. It has also been highly recommended in 
puerperal eclampsia, administered in large doses, but profuse 
bleeding, from the uterus or by venesection, and the adminis- 
tration of thyroid extracts is better treatment. 

DRUGS USED TO STRENGTHEN THE HEART 

Caffeine. — Administration. — Caffeine (theine) is a basic sub- 
stance obtained from the leaves of tea and from the seeds of 
coffee. It is also prepared synthetically. It occurs in white 
silky needles, has a very bitter taste, and is not very soluble in 
water. It is generally used in the form of the official Caffeina 
Citrata, which is a white powder, has a bitter, acid taste, is 
soluble in water, and the dose is 0.30 Gm. (5 grains). A 
pleasant method of administering citrated caffeine is in the 
official Caffeina Citrata Effervescent. This preparation contains 
4 per cent, of the citrated caffeine and effervesces when placed 
in water. The dose is 4 Gm. (1 drachm). 

Caffeine and theobromine are purins. The former is tri- 
me thy lxan thin, and the latter is dime thylxan thin. Caffeine is 
quickly absorbed and acts quickly, and the dose may be re- 
peated in two or three hours, if needed. It is often well to 
administer caffeine hypodermatically, and the official Caffeina 
Sodio-Benzoas, a mixture of caffeine and sodium benzoate, is the 
salt that is most satisfactory for this purpose. It occurs as a 
white powder, is very soluble in water, and the hypodermic dose 
is 0.20 Gm. (3 grains). It should be remembered that caffeine 
is often as well administered in the form of strong coffee as in 
any other way. 

Action. — While caffeine is perhaps the best cerebral and men- 
tal stimulant we possess, and inhibits mental fatigue and allows 
longer continued work, it, of course, cannot take the place of the 
cerebral rest caused by sleep. Consequently, while it stimu- 
lates, it leaves the brain more fatigued after its action is over, 
and when it is used repeatedly as a cerebral stimulant and to 
prevent sleep, when it is necessary for a person to be awake, it 
can do nothing but cause general nerve and brain fatigue, 
unless adequate sleep is obtained. 



DRUGS TO STRENGTHEN THE HEART 215 

Caffeine raises the blood-pressure by stimulating the vaso- 
motor centers, may slow and steady a weak heart by stimulation 
of the vagus center, and thus may strengthen the heart. How- 
ever, if a heart has become irritated by nervous stimulation as 
by hyperthyroidism, or by cerebral irritation, or by a drug, as 
strychnine, caffeine will add to the irritability of the heart and 
will do harm. In other words, in all rapid, irritable hearts 
caffeine in any form, including coffee and tea, should be pro- 
hibited. A slow, weak heart may be made faster and stronger 
with caffeine. 

It has been shown that caffeine will not protect a heart from 
the depressing effects of a coal-tar product, but its combination 
with such, as acetanilid or phenacetin, when these drugs are to 
be administered for headache, may make their action more 
effective. 

While caffeine in most any form seems to prevent fatigue, and 
will allow a patient to go longer without food and without de- 
pression, still it has not been shown that caffeine is a 
valuable muscle stimulant. In muscular exertion it may in- 
crease the nervous irritability, and nervousness or increased 
tension or excitability is well known to interfere with the 
best muscular efforts. Therefore an athlete is better without 
coffee, tea, or caffeine stimulation before a trial of his strength 
is made. 

With most individuals caffeine acts as a diuretic, even if the 
blood-pressure is not much raised. Caffeine is excreted largely 
by the kidneys as dime thylxan thin and uric acid. 

There is no question but that a caffeine habit can be acquired, 
whether as such (perhaps in the form of coca cola) or as a tea 
or coffee habit. Coca cola, tea, and coffee "fiends" are of com- 
mon occurrence. 

Over-action. — Over-action of caffeine is shown by great 
nervous irritability, rapid heart, insomnia, and, perhaps, by 
muscle twitchings. It may also cause both stomach and intes- 
tinal indigestion, as mostly evidenced by increased peristalsis. 
Perhaps some of the indigestion is caused by excessive nervous 
irritability, and it is well known that cerebral irritation can 
cause hyperacidity of the stomach. 



2l6 THE PRINCIPLES OF THERAPEUTICS 

It is not necessary here to discuss the end effects of the 
coca cola habit; it is serious, and is especially harmful to 
children and youth. The cause of the habit is the caffeine in 
the mixture. It is not pertinent to discuss the small amount 
that one glass may contain, or that the civilized world drinks 
tea and coffee freely. The coca cola habit is pernicious. 

Very many individuals drink too much tea or too much coffee, 
and since prohibition was established, the sale and use of tea 
and coffee have been very greatly increased; probably a con- 
servative estimate would be a 25 per cent, increase. With the 
withdrawal of alcohol in all forms the use of substitute stimula- 
tion will necessarily increase, and if more dangerous drugs can- 
not be obtained, the accessible drugging by tea and coffee will 
increase, to the nervous harm of the race. In other words, 
more people will be harmed annually by the excessive use of 
tea and coffee, or by caffeine in some other form, than were 
harmed by alcohol in the year 1918, for instance. 

Civilized man in this age is over-stimulated, and needs 
something to soothe and quiet him. He (and also she) is 
beginning to get that quieting from more tobacco than he (or 
she) ever before used. But if this does not satisfy him, he, also, 
as well as those who do not smoke, will drink more tea and 
coffee. The result is greater nervous tension, greater nervous 
irritability, less sleep, more indigestion, and finally a loss of 
mental balance and of physical strength. We are now menaced 
with the probable overuse of tea and coffee ; hence this warning 
is issued. 

Acute poisoning with caffeine rarely occurs, and serious 
symptoms would rarely be caused by any ordinary amount of 
caffeine except in one who had an idiosyncrasy against it, 
generally evidenced by a more or less persistent tachycardia 
after even a single cup of coffee. In all cases of hyperthyroid- 
ism or of irritability of the thyroid gland, coffee, tea, and all 
forms of caffeine should be prohibited. 

Uses. — The principal use of caffeine is as a circulatory stimu- 
lant, and as such it is generally well administered as a cup of 
coffee, unless it is deemed best to administer it as the citrated 
caffeine; or it may be given in emergencies hypodermatically, as 



DIGITALIS 217 

the caffeine sodio-benzoate.» In collapsed conditions, and in 
all cases of low temperature with a weak or sluggishly acting 
heart, and in mental apathy, as many times occurs in typhoid 
fever, caffeine is a very valuable drug, and is of great benefit. 
In many acute diseases, and especially in typhoid fever, and 
often in pneumonia, a morning cup of coffee is advisable. Of 
course, if there is any cerebral irritation or a tendency to 
delirium, caffeine is contraindicated. In high blood-pressure all 
caffeine should be prohibited. 

As a cerebral stimulant caffeine may be used in emergencies, 
but should not be regularly taken for that purpose. Reporters, 
editors, and night clerks all frequently take coffee to keep them- 
selves awake. Excessive use of coffee for this purpose can but 
be harmful, if taken for any length of time. 

Digitalis. — Administration. — Digitalis (foxglove) is official 
as the dried leaves of the plant. It contains several active 
glucosides, no one of which thoroughly represents the action of 
the drug. The most poisonous of these glucosides is digitoxin. 
Another active glucoside, digitalin, is either crystalline or 
amorphous, and some preparations contain also digitoxin. 
These glucosides, or active principles, are sometimes used 
hypodermatically, but they are irritant, and the digitoxin, as 
stated, is more poisonous than is the drug itself. Consequently, 
for hypodermatic use a sterile, assayed preparation of the whole 
leaf is better. The dose of the leaves is 0.06 Gm. (1 grain), 
and when good leaves are used it is a very efficient and pleasant 
method of administering digitalis. 

The official preparations are the Fluidextract, the Infusion, 
and the Tincture. The dose of the fluidextract is 0.05 mil or 
1 minim). The dose of the infusion is 4 mils (1 fluidrachm), 
and to be of value it must be freshly prepared. A teaspoonful 
(5 mils) equals a little more than 1 grain (0.075 Gm.) of the 
drug. The infusion has long been thought to be of more value 
therapeutically than the tincture, but it is more active only 
because it is made of fresh, active leaves, while the tincture may 
have become old and deteriorated; the action of the tincture 
and the infusion is about the same. The dose of the tincture of 
digitalis, which represents 10 per cent, of the drug, is 0.5 mil 



2lS THE PRINCIPLES OF THERAPEUTICS 

(7^ minims). 0.5 mil of this preparation equals 0.05 Gm. of 
the drug, a little less than 1 grain. 

The proper dose of digitalis in different conditions is not 
agreed upon by clinicians. Small doses frequently repeated, 
though advised by some, seem inexcusable, as the drug acts very 
slowly, and is also slow of excretion. On the other hand, very 
large doses, computed according to the weight of the patient, 
are given by some clinicians, who claim such doses do not cause 
poisoning. The rapid digitalization of a patient, watching 
for mental depression and dropped heart beats as signals to stop 
the drug before vomiting occurs, is the method of administration 
by these clinicians. Other clinicians obtain good effects from 
small doses of an active preparation, not frequently repeated. 
All agree that when the effect of digitalis is evident on the 
heart and circulation, that large doses should no longer be given, 
and that they should be given less frequently, at least not 
more than once or twice in twenty-four hours; and some 
clinicians believe the drug should be stopped, to be repeated 
later. There is a decided difference in patients as to their 
tolerance of large doses of digitalis, probably frequently depen- 
dent upon the individual rate of excretion. 

There are various imported glucosides and assayed digitalis 
preparations on the market, but there is no reason why Ameri- 
can assayed preparations of digitalis are not as active and as 
therapeutically useful as those that have travelled across the 
ocean. An assayed tincture or an assayed fluid preparation in 
ampules for hypodermatic or intramuscular injection, or assayed 
leaves in tablets, or a fresh infusion made efficiently by a skilled 
pharmacist from active leaves, represent all the preparations 
needed for digitalis use. All liquid preparations of digitalis, 
even the tincture, more or less rapidly deteriorate, and the much 
used fat-free tinctures also deteriorate, although they may be a 
little less likely to cause nausea. 

Whatever the preparation of digitalis used, the dose is always 
enough to do the work desired, and that dose will vary not only 
with similar preparations, but with preparations made at dif- 
ferent times by the same chemist. 

Action. — There is no external action of digitalis. On mucous 



DIGITALIS 219 

membranes it is slightly irritant in strong preparations, and 
tends to cause nausea and vomiting when taken on an empty 
stomach. , Large doses may cause diarrhea. Occasionally 
when digitalis is given hypodermatically, unless the preparation 
is especially prepared for that purpose, it may cause an abscess. 
Digitalis is absorbed both from the stomach and intestines, the 
rate of absorption depending upon the preparation used, and 
upon when it is taken, whether on an empty or a full stomach. 
It should be recognized that in conditions of shock digitalis 
may be absorbed very slowly from the alimentary canal. 

The drug does not cause strong systemic effects until at least 
twelve hours after it has been taken, although its action may 
begin in about four hours. The vagus center in the medulla is 
stimulated, and the heart is slowed through the action of the 
vagi nerves. Larger doses may act on the endings of these 
nerves in the heart to more or less prevent the retarding action 
of vagus stimulation. Still larger doses, or excessive doses, will 
more or less paralyze the endings of the vagi nerves, and the 
heart becomes irregular and rapid. Ordinary doses of digitalis 
may retard the conductivity of the auriculo-ventricular bundle, 
and thus slow the heart. Larger doses may cause heart-block, 
and the auricular rhythm will be greater than the ventricular 
rhythm. 

Digitalis acts more on the ventricles than on the auricles, 
and causes more forceful contractions and more complete di- 
astoles. Slowing of the heart rests it, and by better contraction 
and better dilatation and an increased pressure in the aorta, 
there is a better coronary circulation, and therefore im- 
proved nutrition of the heart. It should not be aimed to 
slow a heart by digitalis below 65 or 70 beats a minute, and in 
aortic regurgitation it should not be slowed below 80 beats a 
minute. 

In an ordinary healthy individual and in depressed circula- 
tory conditions, digitalis will ordinarily increase the blood- 
pressure, and in many conditions of disease, with hypertension, 
the blood-pressure will be lowered rather than increased by 
digitalis. In conditions of venous dilatation and venous con- 
gestion, and with the diastolic pressure high, digitalis will often 



220 THE PRINCIPLES OF THERAPEUTICS 

lower the [diastolic and increase the pulse-pressure, to the 
benefit of the patient. 

Digitalis probably rarely causes such local irritation of the 
vasomotor system as to increase the blood-pressure from that 
cause. With healthy individuals it will generally increase the 
output of urine, largely by causing a better tone of the blood- 
vessels of the liver and splanchnic system. Digitalis probably 
does not act on the kidney structure as a stimulant; the increased 
diuresis is entirely due to the increased circulatory tone. 

Over-action. — Undesired action of digitalis is evidenced by 
nausea; perhaps diarrhea; a tight, bandlike feeling in the head; 
too great slowing of the pulse; slight cardiac pains or cardiac 
ache, often of a different type than those which the patient may 
have had before the digitalis was given; dropped beats; the 
hands and feet may be cold, and there may be a continuous 
headache. 

If, when any of these symptoms occur, digitalis is immedi- 
ately stopped, in from twelve to twenty-four hours the above 
symptoms will generally entirely disappear. If, on the other 
hand, the drug is not stopped with the above symptoms present, 
the so-called cumulative effect will occur. Cumulative action 
is evidenced by a slowing of the excretion of urine, and perhaps 
almost suppression, with an exacerbation of all of the above 
symptoms. Cumulative effect will rarely occur with ordinary 
small dosage, even if the drug is given daily for a long period, 
provided nephritis is not present. 

When, during the administration of digitalis, the heart tends 
to beat in couplets, the drug should be stopped, as it is 
seriously affecting the heart. However, generally before this 
effect takes place, loss of appetite, nausea, and headache should 
have caused the drug to be withdrawn. 

Toxic Action. — A toxic dose of digitalis causes the heart to 
become rapid and irregular, with perhaps, on the other hand, 
heart-blocking. The extremities become cold, there is numb- 
ness, occipital headache, disturbed vision, and cardiac death. 

Treatment of Poisoning. — In digitalis poisoning an emetic 
should be given and also tannic acid solutions; later a quick- 
acting cathartic is advisable. There is no physiologic anti- 



DIGITALIS 221 

dote. Dry heat should be applied to the body to dilate the 
peripheral vessels, and hot fomentations to the kidney region 
to hasten elimination. Nitroglycerin is of some value. 

Uses. — There is no drug that equals digitalis in the treatment 
of dilatation of the heart and of broken compensation in valvu- 
lar disease. It is also very beneficial in the treatment of heart 
strain (acute dilatation) from any cause, as from over-work, 
from athletics, from hard marching, etc. It also benefits a 
heart that has been weakened by tobacco. It is generally of 
benefit when there is edema or exudates in any part of the body, 
when there is poor circulation and no serious kidney lesion. 
It may or may not be of benefit in low blood-pressure. Some- 
times in this condition, without edema, and without dilatation 
of the heart, it utterly fails to raise a low pressure. It may be of 
benefit in many cases of myocardial degeneration, but it may 
not be tolerated in such a case, and may do harm. It is rarely 
indicated when there is fatty degeneration. It will not act well 
in irregular action of the heart when the pulse is slow and with 
irregular blood-pressure readings. In this condition other 
heart drugs are indicated. 

A valvular lesion is not an indication for the use of digitalis 
unless there are signs of broken or impaired compensation. On 
the other hand, a heart may badly need the aid of digitalis when 
no valvular lesion can be demonstrated. Hence, before digitalis 
is administered, it should be decided that such an active drug 
is needed. 

It is not purposed here to describe the treatment of heart 
disease, only to suggest the beneficial activity of this drug in ( 
certain characteristic conditions. 

In mitral regurgitation with broken compensation and a con-i 
sequent damming back of the blood in the lungs, then into the 
right auricle and right ventricle, thus causing a sluggish general 
venous circulation, especially in evidence by congestion of the 
portal system and a congestion, and often enlargement, of the 
liver, poor circulation in the stomach and intestines, and sooner 
or later passive congestion of the kidneys, with still later pen- 
dent edemas, digitalis, by increasing the activity of the ventricles 
and causing more contraction at the mitral valve and therefore 



222 THE PRINCIPLES OP THERAPEUTICS 

less leaking, and by slowing the heart, thus increasing its rest 
period and its nutrition, will generally bring about a re-establish- 
ment of compensation. 

In mitral stenosis and compensation beginning to fail, with 
a damming back of blood in the lungs and right ventricle strain, 
and often general venous congestion, digitalis is of especial 
value by slowing the action of the heart so that more blood may 
pass through the narrowed mitral valve into the left ventricle. 
The heart with this defect may be slowed with more benefit than 
in any other lesion; but when the heart has become slowed with 
digitalis, sudden rising from the bed, or from a chair, must be 
prohibited during the intense action of the drug, lest sudden 
death be caused, perhaps by anemia of the brain. 

In aortic insufficiency with broken or breaking compensation, 
the already very large left ventricle is becoming dilated, with 
possibly a temporary mitral leak. All the systemic and bodily 
activities are below par, because of the low blood-pressure often 
found in this condition, the diastolic pressure at least being 
found excessively low. If there is not much hardening of the 
arteries, not too much sclerosis, and not too much myocarditis, 
digitalis will benefit such a patient by bringing back the left 
ventricle strength to its normal compensation, and by toning 
up the heart muscle will eradicate the mitral leak, if it was a 
relative insufficiency and not an insufficiency due to disease. 
By this extra activity the blood-pressure in the aorta is in- 
creased, and therefore proper coronary circulation occurs, and 
the nutrition of the heart is improved. Obviously, it would not 
be of advantage to slow a heart with aortic insufficiency much 
below 80 beats a minute, as the longer the diastole, the more 
blood must flow back through the insufficint aortic opening into 
the left ventricle. This lesion is the one that so frequently 
causes sudden death, either by some sudden rising causing 
anemia at the base of the brain, or causing a sudden dilatation 
and paralysis of the left ventricle. 

In broken compensation in aortic stenosis digitalis may or 
may not be of benefit. The heart in this condition, unless 
badly diseased, is generally slow in order to force the blood 
through this narrowed opening; consequently, for that purpose 



DIGITALIS 223 

digitalis is not needed, and to give more forceful propulsion 
of blood through a narrowed orifice by an extra activity of the 
strong left ventricle may not be of advantage. On the other 
hand, with failing circulation in such a condition, digitalis may 
be of benefit, if it is given in small doses and its results carefully 
watched. If a mitral leak has occurred from strain due to the 
over-filled left ventricle endeavoring to overcome the resis- 
tance at the narrowed aortic valve (i.e., if the ventricle is 
dilated) digitalis may be of benefit up to a certain point of its 
activity, but it should not be pushed. 

It is readily understood that as the circulation is improved 
in any case of broken compensation, the lungs are relieved of 
congestion, the portal circulation is relieved of passive conges- 
tion, the liver becomes nearly normal in size, the output of urine 
by the kidneys is increased, the digestion becomes normal, the 
nutrition improves, the various disturbances of the head and 
brain caused by the sluggish circulation disappear, and the 
patient temporarily recovers. 

Whenever the heart fails from weakness, due to the misuse of 
drugs, such as the coal-tar and synthetic drugs; to the over-use 
of tobacco; to the misuse of coffee and tea; to hard coughing; to 
whooping cough; to asthma; to chronic infection; when the 
heart is pressed upon by a pleurisy or an empyema; and when 
the right ventricle is severely taxed as in emphysema, in all such 
conditions, provided there is no special contraindication, digi- 
talis is of benefit. 

Digitalis may also be of benefit in chronic myocarditis with 
heart weakness, provided the drug is carefully used. Large 
doses should not be given, and the results should be carefully 
watched. In obesity with possibly fat deposits around the 
heart, digitalis may be of great benefit. If there is actual fatty 
degeneration of the heart muscle, digitalis may do serious harm. 

Digitalis should not be used in acute endocarditis or peri- 
carditis, unless, in the latter condition, the heart is laboring. It 
should not be used during acute fever processes, unless possibly 
in the beginning of such a condition, as with most infections the 
heart muscle is more or less affected, and in any acute myocar- 
dial condition digitalis is contraindicated. 



224 THE PRINCIPLES OF THERAPEUTICS 

Lately it has been advocated to administer digitalis in the 
beginning of pneumonia. Because a patient has pneumonia is 
not necessarily an indication to administer digitalis. In certain 
conditions of heart weakness, and when there is prune- juice ex- 
pectoration, or there is a tendency to venous congestions and 
the blood-pressure is low, digitalis may be indicated, pushed to 
the point, as advised, of digitalization, which means to the 
point of the heart showing complete action of digitalis and then 
the drug stopped. But it is believed that it is not good treat- 
ment to give digitalis in the first stage of every case of pneu- 
monia. Digitalis notably fails of good action in the failing 
heart of pneumonia in the later stages. 

In auricular fibrillation, digitalis has almost a specific action, 
and it is now recognized that auricular fibrillation is not infre- 
quent with hearts that are not seriously damaged. With the 
rapid, weak hearts of serious myocardial disease, it may not act 
to advantage, but in auricular fibrillation, which often occurs 
with younger individuals without arteriosclerosis, digitalis 
pushed to full activity will soon stop the paroxysm. Some clini- 
cians advise very large doses, rapidly repeated, to practically 
intoxicate the heart with the drug. It is not often necessary to 
take such a chance of a possible over-action of the drug. Small- 
er doses repeated at six-hour intervals, perhaps in gradually 
increasing doses, is often a safer method. 

It must be remembered in administering digitalis that it acts 
as a muscle trainer, and, except in auricular fibrillation, very 
large doses should rarely be given. The heart should be coaxed 
gradually to greater activity, much as a muscle is trained in 
athletics, rather than to start with excessive stimulation. As 
just stated, however, in auricular fibrillation it may be well to 
intoxicate or really paralyze the heart by inhibiting the con- 
ductivity of the auriculo-ventricular bundle; but many times 
ordinary dosage rather than excessive dosage is as successful 
and safer. A few hours more or less of rapid heart action is 
rarely fatal in these cases, but a too sudden excessive action of 
digitalis may be. Digitalis may also act well in auricular 
flutter. 

The tachycardia of hyperthyroidism is never well treated by 



DIGITALIS 22 5 

digitalis, and the heart will not become slow under the action of 
digitalis, unless the dose is too large for safety, if the cause 
is hyperthyroidism. 

In delirium tremens, with failing heart, good treatment is 
digitalis and ergot, both given hypodermatically. 

Digitalis should not be used when there is internal hemor- 
rhage, unless there is venous oozing, as may occur in circulatory 
weakness. Occasionally in repeated hemoptysis, and especially 
when small amounts of blood are constantly expectorated in 
tuberculosis, digitalis may stop such repeated hemorrhages. 
In all acute hemorrhages from the lungs digitalis is contra- 
indicated ; nitroglycerin, to dilate the peripheral vessels and to 
lower blood-pressure is generally good treatment. 

Digitalis, by increasing the blood-pressure and the general 
as well as local circulation, may cause normal menstruation ; on 
the other hand at times a menorrhagia is well treated by 
digitalis. It may also relieve impotence in the male by improv- 
ing the circulation. 

All dropsical conditions due to weakening of the circu- 
lation are benefited more or less by digitalis, but if the 
edemas are of kidney origin, and if there is nephritis, digitalis 
should not be given. In combined diseased conditions of 
heart and kidneys the decision should be made as to whether 
the insufficiency of the heart causes the disturbance in the 
kidneys, or whether the chronic inflammation of the kidneys 
is the primary lesion. With a passive congestion of the kidneys 
caused by a defective heart, with albumin and casts appearing 
in the urine, digitalis will be of benefit. If, however, the 
kidneys are so diseased that an hypertrophied heart has finally 
become insufficient, owing to the excessive work that it was 
asked to do, digitalis in small doses may be of benefit; but even 
in such doses it is likely to make the excretion of the kidneys 
less. This is especially true in high blood-pressure caused by 
kidney lesions, and with such blood-pressure and kidney lesions, 
digitalis is generally contraindicated. 

Always in heart-block, and generally when coronary disease 
has been diagnosed, digitalis is contraindicated. Occasionally, 
coincident with coronary disease is a degenerated and dilated 
15 



2 26 THE PRINCIPLES OF THERAPEUTICS 

heart. If edema is caused in such a condition, and much 
dyspnea, digitalis in small doses sometimes is of benefit, but 
it should be used with care. 

Strophanthus. — Administration. — Strophanthus (African ar- 
row-poison) occurs as dried seeds, but is never used as such. 
The only official preparation is the tincture, which represents 
10 per cent, strength of the crude drug, and the dose is 0.5 mil 
(73^ minims). 

The most active part of this drug is represented by a 
mixture of glucosides, which is official under the name of 
Stro phanthinum. 

Strophanthin occurs as a white or yellowish powder, which is 
very soluble in water. This preparation is generally admin- 
istered intramuscularly or intravenously, and the Pharma- 
copoeial dose is J60 of a grain. A crystallized preparation of 
strophanthin, a glucoside, is recognized by the N.N.R., 1920, 
under the title of Ouabain, Crystallized. The intravenous or 
intramuscular dose of this preparation is 3<L20 of a grain. 
Neither this preparation nor the strophanthin of the Pharma- 
copoeia should be administered intravenously, ordinarily, 
more than once in twenty-four hours, and rarely should it be 
given more than twice at the same period. Strophanthin 
should not be given if the patient has been taking digitalis, as 
there is danger of an excessive action on the heart under these 
conditions. Solutions of strophanthin and of ouabain rapidly 
deteriorate. They should test neutral or faintly acid. 

Action. — Strophanthus has no action on the unbroken skin. 
The seeds, which contain a volatile oil, are irritant to mucous 
membranes, and, consequently, in large doses all preparations 
cause nausea, vomiting, and diarrhea. In very small doses the 
tincture may act as a bitter tonic on account of this slight 
irritant action, while larger doses cause more or less indigestion, 
and often diarrhea. 

It was long supposed that strophanthus acted on the heart 
somewhat similarly to digitalis, only much less powerfully. It 
has, however, been proved, that for the best strophanthus 
effect on the heart the glucoside preparation of strophanthin, or 
ouabain must be given intramuscularly, or better, intravenously, 



STROPHANTHUS 227 

at least for quick effect. When so given it will frequently, at 
least for a time, save life by stimulating a failing heart. 

The heart muscle is stimulated by strophanthin, and a rapid 
heart is somewhat slowed ; the blood-pressure is somewhat raised 
by the increased heart action, although the arterioles are not 
contracted by it. 

In ordinary dosage strophanthus, given by the mouth, in the 
form of the tincture may have a slight sedative effect on the cen- 
tral nervous system. It has no diuretic effect, except when 
the heart is stimulated by injections of strophanthin. 

Over-action. — When the tincture of strophanthus is given by 
the mouth, the only undesired effect evident is gastrointestinal 
irritation, and some patients cannot take even a small dose 
without its causing such irritation. 

Toxic Action. — Large doses of strophanthus, unless immedi- 
ately vomited, produce paralysis through its action on the nervous 
system. When given intramuscularly or intravenously the 
drug, if given in large doses, may cause death by action on the 
heart. When the drug is given subcutaneously it may cause 
abscesses. 

If poisoning occurs by way of the stomach, an emetic should 
be given and later a saline cathartic. If poisoning occurred 
after injection of strophanthin, the treatment would be purely 
symptomatic, and caffeine, atropine, camphor, and dry heat 
to the body is the treatment indicated. 

Uses. — The tincture of strophanthus should hardly be con- 
sidered a useful preparation in cardiac disturbances. It has 
seemed, however, to be of value, at times, in the conditions for 
which digitalis was being used; but it is quite probable that the 
apparent good effect the strophanthus had in these cases was 
because the digitalis was stopped, as but little strophanthin action 
on the heart can be obtained from strophanthus by the month. 
However, in nervous, irritable hearts, or when there is general 
nervous irritability with associated cardiac irritability, the 
tincture of strophanthus may have a good effect. 

The most useful action from this drug is in sudden heart 
failure, when strophanthin, or ouabain, should be given intrave- 
nously. Its greatest value is when there is no real defect of the 



2 28 THE PRINCIPLES OF THERAPEUTICS 

heart muscle, but in such conditions as sudden failure in typhoid 
fever or in pneumonia, or in collapse from shock, or perhaps when 
there is great slowing of the heart from partial heart-block, or 
in the Stokes-Adams syndrome. Strophanthus does not tend 
to aggravate a heart-block as does digitalis. It should be 
again emphasized that it should not be given when the patient 
is under the influence of digitalis. In emergencies the dose 
should be 0.0005 Gm., (half a milligram, }{ 2 o grain) of a good 
crystallized ouabain. Sterile ampules can be obtained for intra- 
venous use. 

Strophanthus does not act well in decompensation with 
general edema and dropsy. Also, it is rare that such a condi- 
tion has developed without the patient being under the 
influence of digitalis. 

Nux Vomica. — Administration. — Nux vomica occurs as dried 
seeds, but is not used as such, and the only official preparation 
that is needed is the Tinctura Nucis Vomica, which represents 
10 per cent, of the crude drug, the Pharmacopceial dose of which 
is 0.5 mil (7^ minims). The only real use for this preparation 
of nux vomica is as a bitter tonic, as it is stimulant to the diges- 
tion, and to the gastrointestinal activities. It would rarely be 
given in sufficient doses to cause strychnine activity. 

As the only real value of nux vomica is due to its alkaloid, 
strychnine, the activities of this drug will be described under 
that heading. 

Strychnine. — Administration. — This alkaloid of nux vomica is 
rarely used except in the form of one of its official salts, namely, 
the nitrate and the sulphate. As there is no advantage of the 
nitrate over the sulphate, the sulphate should be the preparation 
of choice. The sulphate of strychnine occurs as colorless white 
crystals or as a crystalline powder, is soluble in considerable 
water, and the dose is 0.001 to 0.002 Gm. (}{q to }{q grain). 

Action. — Strychnine has no action on the external skin, and is 
used only for administration by the mouth, or hypodermatic- 
ally. Strychnine is rapidly absorbed and rapidly stimulates the 
central nervous system, especially the motor tract of the spinal 
cord. It stimulates all of the nerve centers; stimulates the 
vasomotor centers, therefore raises the blood-pressure; stimu- 



STRYCHNINE 229 

lates all glands and muscles; aids digestion; and increases peri- 
stalsis. It is slightly diuretic and is excreted in the urine. It 
increases the activities of all the special senses, is a respiratory 
stimulant, and is stimulant to the heart. 

Over-action. — Strychnine may greatly increase the nervous 
reflexes and cause nervous irritability and sleeplessness, and it 
may cause a rapid heart to be more rapid, and a high blood- 
pressure to be higher. Hence it may do harm by causing too 
much general stimulation. 

Toxic Action. — Poisoning causes tetanic convulsions, during 
which the patient may die from asphyxia, or, if the convulsions 
are frequently repeated, he may die from exhaustion. 

Treatment of Poisoning. — If the drug has been taken into the 
stomach, emesis should be immediately caused, then tannic 
acid and water should be given; if the patient does not 
vomit sufficiently, the stomach should be washed out. If 
convulsions have already occurred, chloroform inhalations 
should be given, in order to facilitate washing out the stomach. 
Then chloral 2 Gm. (30 grains), and sodium, or potassium, 
bromide 3 Gm. (45 grains), should be given by the rectum, 
the patient being under the influence of chloroform. The 
patient should also be catheterized. 

Uses. — Indications for the use of strychnine are: (1) to 
increase the appetite; (2) to increase intestinal peristalsis; (3) 
to promote general metabolism; (4) to stimulate the nervous 
system; (5) to stop profuse sweating; (6) to improve the 
circulation. 

To meet the first two indications it is best given in the form 
of the tincture of nux vomica, in a dose of 1 to 5 drops, three 
times a day, before meals. Or, if the bitter is objected to, 
strychnine sulphate may be given in a dose of 0.001 to 0.002 
Gm. (3^o to }£q grains) three times a day, after meals. In this 
dose the strychnine will also more or less meet the next two 
indications, namely, to promote metabolism, and to stimulate 
the general nervous system. Therefore, strychnine sulphate, in 
properly selected cases, increases the appetite, the digestion, 
the normal movements of the stomach and intestines, increases 
all secretions, and awakens a sluggish nervous system. How- 



23O THE PRINCIPLES OF THERAPEUTICS 

ever, in nervous tire and debility it should be recognized that 
strychnine is a whip and can only develop the reserve energy 
and strength without causing much recuperation of nervous 
energy. What such a patient generally needs is rest, both 
physical and mental. Strychnine will give neither, although 
it will give temporary increased strength. 

Strychnine is used more or less extensively in all kinds of 
paralysis, but it should always be associated with more or less 
massage and electrical treatment. It should not be given in 
irritable, inflamed, or acute conditions of the spinal cord or 
brain. If pain is caused by such inflammation, strychnine will 
increase that pain and increase muscle irritability and muscle 
spasms. In paralysis, at the stage when general stimulation is 
desirable, strychnine has been frequently injected into the 
paralyzed muscles. There seems to be no good reason for such 
localization of treatment, as the strychnine must go to the 
motor tract of the cord to be of any benefit to the paralyzed 
nerves and muscles. By the mouth, however, in most paretic 
conditions, in which there is no acute central lesion, strychnine 
is of benefit, and in the paralytic stage of neuritis it is beneficial 
when associated with local stimulation of the paralyzed muscles. 

In prostrating sweats either of tuberculosis or of acute disease, 
and in convalescence, when all tissues are relaxed, there is no 
drug more beneficial than strychnine. In the sweating of 
tuberculosis it is well associated with atropine. 

Before discussing the indication for the use of strychnine to 
improve the circulation, it should be urged that the sooner we 
leave the " strychnine age" the better. Too much strychnine 
is administered to-day during all acute diseases, and especially 
in the first stages of acute disease, and in the later stages with 
circulatory failure too large doses of strychnine are given. 
In the first place, during acute disease it is much better for a 
patient to rest, mentally and physically, rather than to be 
stimulated by this or any drug. In the second place, in acute 
cardiac weakness in serious illness strychnine often fails. It 
rarely raises the blood-pressure in conditions of shock, and it 
rarely is of benefit in serious heart weakness. 

On the other hand, with low temperature, without delirium, 



VASOCONSTRICTORS 23 1 

with much drowsiness, and a general sluggish metabolism, and 
with all the vital centers acting sluggishly, strychnine is the 
drug of choice, and may be given once in six hours by the 
mouth, in a dose of from o.ooi to 0.002 Gm. (J^q to 3^0 grain) , 
depending on its effect on the patient. If the drug causes the 
patient to be sleepless, restless, and irritable, or if the heart is 
made more rapid, it should be stopped, or at least it should be 
given in smaller doses. If the patient is very much depressed, 
the temperature low, and the skin moist and cool, or if there is 
a tendency to collapse, the strychnine should be given hypoder- 
matically once in six to twelve hours, but not in large doses, and 
not more frequently. This is not to state that it may not be 
advisable, if strychnine has not been given at all, to administer, 
in certain acute shocked or collapsed conditions, a large dose of 
strychnine, even as much as %o °f a g^ 11 ? hypodermatically, 
but strychnine should not be relied upon to save a patient from 
shock or collapse, and to give large doses frequently is inex- 
cusable. It will not raise the blood-pressure in such conditions, 
it will not strengthen the heart, and many times prevents 
normal cardiac diastole. The heart becomes irritable, and 
does not have its normal complete rest cycles. Again it 
should be stated that strychnine, though one of our most useful 
drugs, is used too much at the present time. 

In sudden heart failure during chloroform or ether narcosis, 
one large dose of strychnine may be given hypodermatically, 
not to be repeated; but in all shocked conditions the value of 
atropine and caffeine associated with strychnine should not be 
forgotten. 

DRUGS USED TO CONTRACT THE BLOOD-VESSELS 
VASO -CONSTRICTORS 

All drugs that strengthen the heart more or less increase the 
blood-pressure, but in emergencies atropine and caffeine are the 
most valuable drugs for this purpose. The drugs that cause 
local contraction of the blood-vessels, i.e., styptics, are not used 
to raise the general blood-pressure. 

In hypertension neither atropine nor caffeine should be 
administered as a drug, and the caffeine beverages should not 
be allowed. Both of these drugs are very valuable in depressed, 



22,2 THE PRINCIPLES OE THERAPEUTICS 

low blood-pressure states, especially when the temperature is 
low in serious illness. Pituitary and suprarenal extracts will 
immediately raise the blood-pressure when given on the tongue, 
or hypodermatically. The latter raises the blood-pressure 
more than the former, but its action does not last as long. 
Pituitary extracts raise the blood-pressure, sustain it for some 
time, and at the same time are stimulant to the heart and have 
a diuretic action. 

Ergot. — Administration. — Ergot of Rye is a fungus growing 
on rye, and occurs as a brownish-black substance which has an 
oily, nauseating, disagreeable taste. It is not used as such, but 
in the official preparations of Extractum Ergoke and Fluidex- 
tr actum Ergotce. The extract of ergot in pure form, sometimes 
termed ergotin, occurs as a black pillular mass, the dose of 
which is 0.25 Gm. (4 grains). When this preparation is prop- 
erly made from good ergot, it is efficient, but generally the 
fluidextract is the preparation of choice, the dose of which is 2 
mils (30 minims). Ergot varies greatly in strength, and there- 
fore in activity. The ordinary fluidextract is irritant when 
administered hypodermatically or intramuscularly, but assayed 
fluid preparations are obtainable (both in sealed small bottles 
or in ampules) which are not irritant and are actively efficient. 

Ergot contains several active principles, ergotinine, ergo- 
toxine, tyramine, and histamine. Ergotoxine is a hydrate of 
ergotinine, and has a somewhat similar action to epinephrine. 
Tyramine is chemically similar to epinephrine and acts like 
epinephrine. It is formed from tyrosin by putrefactive pro- 
cesses, and is apparently the active ingredient of watery prepa- 
rations of ergot, which probably do not contain ergotoxine. 
Histamine is an active principle of ergot, but occurs in the 
drug in very minute amounts. 

Action. — Ergot is irritant to the stomach, sometimes even 
in small doses, and with some patients it always causes nausea 
and vomiting, even when given on a full stomach. When given 
hypodermatically it may cause nausea and vomiting by acting 
on the vomiting center. It is absorbed more or less rapidly, 
and is stimulant to all unstriped muscle fiber. It increases 
peristalsis, and therefore promotes activity of the bowels. It 



ERGOT 233 

tends to raise the blood-pressure by causing contraction of the 
arterioles, but at times it lowers blood-pressure. 

It strongly stimulates contraction of the uterus when it is 
dilated, and more especially during and after parturition. 
Even small doses may cause tonic contractions of the uterus 
during parturition, which would be dangerous to both the 
mother and child. Consequently, ergot should never be given 
until the child has been born, and rarely until after the placenta 
has been expelled. 

Ergot acts as a sedative to the central nervous system, per- 
haps by controlling the circulation in the nervous tissues. It 
certainly is many times beneficial in acute cerebrospinal inflam- 
mations, and is especially of benefit when there is edema of the 
brain, as occurs in delirium tremens and in low typhoid states. 

Over-action. — Ergot may raise the blood-pressure too high, 
and therefore cause over-exertion of the heart, and heart pains. 
It may cause cold hands and feet, from too great a contraction 
of the blood-vessels, and it may cause severe uterine pain, 
when it is used to stop menorrhagia. 

Toxic Action. — Acute poisoning from ergot is rare, although 
if vomiting and purging is not caused, and much of the drug is 
absorbed, there may be severe headache, ringing of the ears, 
dilatation of the pupils, a sense of chilliness, coldness, and 
perhaps tingling and numbness of the extremities. It is 
likely to cause abortion in pregnancy. 

Chronic ergot poisoning is rarely seen, although it can occur 
from eating diseased rye and flour, and has occurred in epidemics. 
Two forms of ergotism occur, the nervous type, in which there 
are all kinds of nervous sensations from itching, numbness and 
anesthesia to actual gangrenous conditions; the other type 
causes gastrointestinal symptoms. There may also be cerebral 
types. 

Treatment of Poisoning. — Acute poisoning should be treated 
by evacuation of the stomach and intestines, and by all means 
possible to dilate the peripheral blood-vessels, as hot baths, 
dry heat, nitrites and alcohol. 

Uses. — Ergot has been most used to cause contractions of the 
uterus in all bleeding from this organ. It is purely symptomatic 



234 THE PRINCIPLES OF THERAPEUTICS 

treatment, and while it may stop bleeding at the time, the 
cause of the hemorrhage must be sought and properly treated; 
during its action it may cause severe uterine pains. It is 
used after parturition much less frequently than formerly. 
It is perhaps always of value after chloroform has been 
used as an anesthetic during parturition. Its disad- 
vantage is in sometimes preventing the normal after-pains, 
which are necessary to evacuate clots and shreds of membrane. 
Pituitary extracts are much more frequently used to-day than 
is ergot. 

The value of ergot in promoting intestinal peristalsis in 
semi-paretic conditions, as often occurs after abdominal opera- 
tions, is not generally recognized. For this purpose an aseptic 
preparation, given intramuscularly, is often efficient in promot- 
ing normal peristalsis. Ergot should not be given when there 
is intestinal obstruction, nor should it be given if there is high 
systolic blood-pressure. 

The value of ergot in acute cerebrospinal meningitis is not 
recognized. Intramuscular injections will many times quiet the 
patient and prevent the necessity of administering morphine 
for pain. If morphine is needed, ergot will prolong the sedative 
action from a single dose, and will also cause a smaller dose to 
be effective. Ergot is of great value in delirium tremens, in 
wet-brain, and in overcoming a narcotic habit, more especially 
when these conditions are associated with a failing heart and 
low blood-pressure. 

Perhaps one of the most efficient uses of ergot is in failing 
heart and circulation in serious conditions, and in all kinds of 
shock and collapse. For these purposes it must be given in 
aseptic solution intramuscularly, best into the deltoid muscle. 
The slight swelling that occurs should be covered with some 
simple wet dressing, and the swelling will soon disappear. 
With proper care (the preparation must be first class and 
aseptic) an abscess from injections of ergot need never occur. 
In these emergencies the ergot injection should be repeated 
once in three hours for two or three times, and then once in six 
or twelve hours for a series of doses, depending on the effect. 
Delirium can be quieted, a stupid brain may be cleared, low 



VASODILATORS 235 

blood-pressure may be raised, and a failing heart may be 
braced by ergot thus administered. 

In serious acute collapse from broken compensation in 
valvular lesions, with cold, clammy skin, blue lips, and acute 
edema of the lungs, ergot intramuscularly, associated with 
venesection to relieve the laboring, dilated heart, may save life. 
In the heart failure of pneumonia it will at times save life. 

Ergot is of value in some forms of asthma associated with 
nervous irritability, and it may be of benefit in hyperthyroidism, 
and in hysterical conditions. In diabetes insipidus, the cause 
being cerebral, probably pituitary, ergot is of benefit, and may 
even aid in curing the condition. Full doses should be given 
by the mouth. 

Ergot should not be given when there is internal hemorrhage, 
and it is a mistake to raise the blood-pressure in hemoptysis, for 
instance. In such conditions the opposite effect is desired and 
nitrites should be administered. 

In depressed conditions, and in vasomotor ataxic conditions 
in which there is an instability of the blood-pressure with head- 
ache and insomnia, ergot is often of benefit, improving the 
circulation, stopping the headache, and causing normal sleep. 

Tyramine Hydrochloride, N.N.R. — This preparation is pro- 
duced synthetically, but it also may be prepared from ergot. 
It occurs as a white crystalline powder, soluble in water, and is 
used mostly hypodermatically in doses of 0.02 to 0.04 Gm. 
(3i$ to % grain). It may also be administered by the mouth. 

Its action resembles that of epinephrine. It contracts the 
uterus (but not as actively as does pituitary extract) and raises 
the blood-pressure quite rapidly when given hypodermatically, 
but in about half an hour the blood-pressure has returned to 
normal. It may increase extra-systoles, and is not a reliable 
drug in heart failure. Other drugs are better. 

DRUGS USED TO DILATE THE BLOOD-VESSELS 
VASO-DILATORS 

These drugs are used to lower blood-pressure, consequently, 
to discuss the indications for them we must briefly refer to the 
cause of high blood-pressure or hypertension. 



236 THE PRINCIPLES OF THERAPEUTICS 

The causes of systolic hypertension may be briefly enumer- 
ated as follows: 

The rapid, nervous tension of our lives. 

Too much coffee and tea. 

Too much tobacco. 

Hyperthyroidism, which either stimulates to extra secretion 
the posterior lobe of the pituitary, or the adrenals, or both; or 
hyperthyroidism allows substances to circulate in the blood 
which irritate the blood-vessel walls to cause vaso-contraction 
or which stimulate the vasomotor center. 

Substances absorbed from the intestinal canal in intestinal 
indigestion which cause vaso-constriction. 

Strenuous athletics which cause cardiac hypertrophy. 

Hard labor which causes cardiac hypertrophy. 

Serious acute infection of years before, which has caused 
glandular disturbances which tend toward hypertension. 

Some forms of chronic infection may cause hypertension by 
disturbing glandular secretions. 

Syphilis. 

Glandular disturbances of the menopause often cause hyper- 
tension. 

Kidney disease. 

These may not be all of the causes of hypertension, but in- 
creased arterial pressure is the forerunner of disease in some part 
of the body, and hypertension soon causes symptoms of its own 
which may require treatment. 

The most frequent symptoms are headache, nervousness, 
restlessness, insomnia, increased frequency of urination espe- 
cially at night, dizziness, flushing, hypertrophy of the left ven- 
tricle, and symptoms of cardiac tire. Such symptoms occurring, 
means must be taken to lower the pressure. However, without 
symptoms, a pressure that is not very high does not require 
treatment. 

It is not purposed here to outline the treatment of hyperten- 
sion, but the list of causes that produce this condition should 
lead to the elimination of all removable etiologic factors, and 
especially should warn against such conditions as may cause 



VASODILATORS 237 

hypertension in the future. In other words, prevention of 
hypertension should be the watchword of this age. 

It is not often wise to lower chronic high blood-pressure by 
drugs that weaken the heart, although occasionally small doses 
of aconite, or a coal-tar drug, or chloral, may be used for this 
purpose. 

Anything that produces watery purging will always lower the 
blood-pressure, but such treatment would be for an emergency, 
and should not be carried out daily. On the other hand, daily 
free movements of the bowels are essential in hypertension, as 
constipation and intestinal putrefaction will always tend to 
increase the blood-pressure. 

In hypertension caused by thyroid disturbance, by intestinal 
putrefaction, and by kidney disease, it is essential to either 
deprive the patient entirely of meat and all purins, or at least 
to greatly curtail their intake. 

In the hypertension of the menopause, corpus luteum prep- 
arations are of benefit in some instances, and thyroid extracts 
in other instances. In subsecretion of the thyroid with hyper- 
tension, and especially if there is a history of syphilis, the 
iodides are indicated, and will lower pressure. 

The various methods of applying heat to the body will lower 
pressure, such as body baking, electric light baths, Turkish baths, 
and the ordinary hot bath, provided cold applications are not 
given immediately after the heat treatment. Warm weather 
and hot climates lower blood-pressure; cold weather and cold 
climates raise the pressure. 

In emergencies venesection may be done and considerable 
amounts of blood removed, but the lowered pressure from vene- 
section is not likely to last more than a few days; consequently, 
this treatment is rarely indicated. 

The drugs that are most used to dilate the blood-vessels and 
therefore lower pressure are the nitrites. Alcohol will always 
lower the blood-pressure by dilating the peripheral blood- 
vessels, but it should not be used in hypertension. It is of value 
in dilating the peripheral vessels after chilling, and in certain 
conditions in severe illness. Properly administered, with high 
fever, it will increase evaporation and sweating and be of 



238 THE PRINCIPLES OF THERAPEUTICS 

benefit. It is not a cardiac stimulant, and should not be used 
in shock. 

It should be noted that many a patient with high pressure 
tolerates, and thrives on, this pressure for years with no serious 
consequences. Also, when some patients with high pressure 
have that pressure lowered, they become dizzy, weak, and in- 
capacitated. Consequently, the actual lowering of the pressure 
by drugs should be considered a matter for as careful decision 
and care as is the decision to give digitalis in disturbances of the 
heart. 

Alcohol. — Administration. — This preparation must contain 
not less than 92.3 per cent, by weight of alcohol, while the official 
Alcohol Dehydratum, absolute alcohol, must contain 99 per cent, 
by weight, and the official Alcohol Dilutum contains from 41 to 
42 per cent, by weight. The so-called denatured alcohol is 
alcohol to which has been added about 10 per cent, of wood 
alcohol and about 0.5 per cent, of benzene. Denatured alcohol 
should never be used externally or internally. 

The alcohol of the Pharmacopoeia and the alcohol of whiskey 
and brandy is ethyl alcohol. Wood alcohol is methyl alcohol. 
Ethyl alcohol is largely produced by fermentation of grape sugar 
with yeast. A sweet wine is one in which some of its sugar is 
unfermented, while a dry wine is one where the sugar has all 
been fermented. Whiskey and brandy contain from 40 to 50 
per cent, of alcohol; sherry and port about 20 per cent.; gin and 
rum 40 to 50 per cent.; the clarets about 10 to 12 per cent.; 
champagne about 10 to 12 per cent.; ales 5 to 7 per cent.; the 
beer that used to be about 4 per cent., to what it now is, about 
0.5 per cent. 

If alcohol is used therapeutically, the dose is about 30 mils 
(1 rluidounce) for an emergency, and about 5 to 10 mils (1 to 2 
rluidrachms) given every two hours as long as the patient re- 
quires such treatment. It should be more or less diluted, de- 
pending upon the object for which it is used. Quick absorption 
and slight primary stimulation will be best obtained when the 
solution is strong. When such rapid action is not desired, and 
it is used only to cause general vasodilatation, or when it is 
administered as a food, it should be well diluted. 



ALCOHOL 239 

Action. — Externally, alcohol in strong solution, especially 
when rubbed on is slightly irritant, and causes flushing and con- 
gestion of the skin. If strong alcohol is allowed to evaporate 
from the surface the skin is cooled ; rapid cooling, as by fanning, 
will cause slight benumbing of the skin. Alcohol or cologne 
is sometimes used in this manner to relieve headache. Strong 
preparations of alcohol are astringent to the skin, mildly hemo- 
static, and more or less antiseptic. Alcohol rubs tone up the 
skin and muscles, while sponging with it, in more or less con- 
centration, will reduce temperature. In low temperature the 
alcohol should be warm. A dash of alcohol in a basin of water 
does not constitute a solution for an alcohol bath or for alcohol 
sponging, although it may be pleasing to the sense of smell. 
Repeated use of alcohol on the skin^tends to dry it; therefore a 
dry, scaly, eczematous skin should not receive such treatment. 
An oily, over-secreting skin is well treated by alcohol, and if 
it is desired to harden any part of the skin alcohol is efficient. 

On the mucous membranes, alcohol is irritant and slightly 
astringent, unless very much diluted. 

Alcohol is rapidly absorbed from the gastrointestinal tract, 
and when taken before meals tends to stimulate the desire for 
food, but irritates the stomach, and when repeatedly taken in 
that manner may cause chronic gastritis and indigestion. A 
large amount of alcohol taken with a meal will inhibit the diges- 
tion. Alcohol on an empty stomach is rapidly carried to the 
liver, and sooner or later inhibits its activities, unless the doses 
taken are small. Warm alcohol in any form is more or less 
stimulant to the intestines, causing increased peristalsis, acting, 
like all aromatics, as a carminative. Concentrated solutions 
will not only inflame the stomach, but may cause a duodenitis. 

There is no question that alcohol may be used as a substitute 
for food in the place of starch and sugar. In emergencies it may 
thus sustain life, but it cannot be long used as a food without 
its undesirable activities becoming evident. About 1 3^ ounces 
of alcohol, or 3 ounces of whiskey, will sustain the body without 
loss for twenty-four hours. Much less than this amount may 
be advisable in certain conditions in acute illness when only a 
small amount of other food is allowed. 



240 THE PRINCIPLES OF THERAPEUTICS 

Alcohol may work harmfully in several ways. It may 
cause indigestion and disturbance of the liver. This may cause, 
later, congestions of the liver, insufficiency of the bile, and in- 
testinal indigestion; consequently more irrtiants reach the 
kidneys, and kidney irritation develops. Or, alcohol may in- 
crease the blood-pressure by allowing irritants to circulate in 
the blood. These irritants, or the alcohol itself, may disturb 
the brain by actual irritation or by chemical reaction with sub- 
stances in the brain. On the other hand, if a man is otherwise 
well, alcohol may increase his appetite, cause him to eat more 
than he needs, and, it being more readily burned than are the 
fats, cause him to deposit extra amounts of fat and to increase 
his weight, largely on his abdomen. 

Strenuous exercise and hard labor will allow a man to use 
more alcohol without harm than can be used by a man of seden- 
tary habits; however, alcohol will not increase his ability to 
work, but on the contrary will diminish his strength. Also, one 
cannot do as good mental work under the influence of alcohol as 
without it. 

Alcohol was long used as a stimulant to the circulatory 
system. During previous sturdy ages it may have had the 
effect desired, by lowering the blood-pressure, dilating the peri- 
pheral blood-vessels, and weakening a too strenuous heart; but 
in the present age it is never a cardiac stimulant. It is abso- 
lutely contraindicated in shock, although in sudden chilling and 
sudden syncope it may cause the stimulating effect desired. 
Repeated taking of alcohol is likely to cause peripheral dila- 
tatio^of the surface vessels, especially on the face and around 
the nose, although not every such condition of dilated capillaries 
of the face and nose is due to alcohol. 

Small doses of alcohol are stimulant to the nervous systems 
of those who are not used to its effect, and sedative to the 
nervous systems of those who are used to it. It may cause 
sleep in sufficient doses, by dilating the peripheral circulation 
and lowering blood-pressure. Very large doses may cause 
much cerebral excitement, or may cause stupor, and later coma. 

Over-action. — The over-action of alcohol is evidenced by 
cerebral excitement; a rapid, bounding pulse; flushing of the 



ALCOHOL 241 

face, and a strong odor of alcohol on the breath. If alcohol is 
used medicinally these symptoms occurring show that the dose 
is too large or is being too frequently repeated. However, it is 
almost inexcusable to give a sufficient amount to cause such 
symptoms. 

Toxic Action. — Alcohol in toxic doses may cause serious 
cerebral excitement and, later, heart weakness and stupor. 
Delirium tremens is likely to be caused by privation of alcohol in 
those who have been hard drinkers, or who have been having a 
period of excessive drinking. The body temperature is very 
much lowered after excessive doses, and individuals who are 
suffering from such a condition readily become chilled and 
develop internal congestions, typically pneumonia. Under 
present conditions it may become very rare for a physician to 
be called to treat a man in alcoholic coma, but it may be worth 
while to still remember that a patient may be suffering from 
narcotic poisoning, uremic or diabetic coma, apoplexy, or cere- 
bral injury and yet have the odor of alcohol on his breath. 

Treatment of Poisoning. — The patient should be vomited ; if 
the heart is in good condition, best with apomorphine hypo- 
dermatically. If there is cerebral excitement, scopolamine 
hydrobromide should be given hypodermatically, an ice cap 
placed on the head, and perhaps a dose of bromide or chloral, 
or both, given. If the heart is weak, ergot intramuscularly 
should be given, and if there is no delirium, coffee by the mouth. 
Digitalis may be needed. This is best administered hypoderma- 
tically or intramuscularly. Morphine is generally inadvisable, 
as these patients require a large dose to quiet them, a small dose 
only increasing their excitement. 

Death from alcohol is caused by paralysis of the respiratory 
center, although the heart may fail and the death may be 
largely from exhaustion. In comatose conditions the bladder 
should be catheterized more or less frequently. 

Uses. — The external use of alcohol has already been referred to 
under the heading of " administration." Besides the uses 
there suggested wet dressings with alcohol are often of value in 
sprains and acute inflammations of a part, especially of the 
joints. A small towel or napkin wet with one part of alcohol 

16 



242 THE PRINCIPLES OF THERAPEUTICS 

and three parts of cold water is wrapped around the joint, cov- 
ered with oil silk or rubber tissue, and the whole bound firmly, 
but not too tightly, with a bandage. This alcohol pack tends 
to relieve inflammation. 

Cushing 1 describes the value of injections of alcohol in 
trigeminal neuralgia and states that, though not without some 
danger, these injections into the maxillary and mandibular 
nerve trunks are preferable to peripheral neurectomies. If the 
neuralgia is refractory the injections should not be pushed, but 
the more radical surgical operation should be done. 

The internal therapeutic use of alcohol should be entirely 
separated from a consideration of alcohol as a beverage or from 
the prohibition standpoint. Alcohol is a drug, and as such has 
many valuable uses. It is absolutely inexcusable to order 
alcohol for any chronic condition, or as an appetizer, or as a 
sleep producer, except under very unusual conditions. There 
are times, for individuals who are very weak, and in old age, 
when a little bitter tonic which contains alcohol, taken before 
meals, is perfectly legitimate treatment. In the age when 
alcohol could be obtained, it was a perfectly harmless proposi- 
tion, in old age, with sleeplessness, to order a small amount of 
alcohol in the form best suited to the individual, to be taken 
before bedtime. It is in such cases much less likely to do harm 
than is a stronger hypnotic drug. 

In sudden syncope, when whiskey or brandy is available, a 
dose of it may quickly relieve the condition and revive the 
heart and circulation. It never does any harm in such a case, 
and always some good. 

In acute illness when but little food can be taken, and when 
the skin is dry and hot, small doses of alcohol, as a teaspoonful 
of whiskey once in three or four hours, taken well diluted, will 
often slow the pulse, lower the temperature, and make the 
patient much more comfortable. Large doses of alcohol are 
never needed in illness, and if they ever saved life in the pneu- 
monias of years ago, as once strongly advocated, they cannot 
save life now. In all depressed conditions in acute illness 
alcohol is contraindicated. 

1 Journal A. M. A., Aug. 14, 1920, p. 441. 



ALCOHOL 243 

When a vaso-dilator is needed in high fever, a small dose of 
nitroglycerin, J-^oo of a grain once in three or four hours, may- 
act on the circulation as does alcohol. Generally any serious 
illness to-day may be treated satisfactorily from start to finish 
without a single dose of alcohol, while twenty-five years ago 
perhaps but few patients went through an illness without alco- 
hol, and fifty years ago perhaps no one was treated throughout 
an illness without alcohol. But this does not signify that it was 
a mistake to give alcohol to these patients, although unquestion- 
ably many received more alcohol than they needed. It 
simply means that the general systemic condition of our pa- 
tients has changed, they then needed more or less relaxation. 
We will probably soon find that we can satisfactorily carry a 
patient through illness without strychnine ; this is the strychnine 
age, and most everyone who is ill receives it. We will probably 
soon find that, in this neurotic age, all patients are over-stimu- 
lated, and would be better without strychnine. 

Alcohol has been very frequently resorted to both by the 
laity and by the profession, in combination with other treat- 
ments, to cause vaso-dilatation and profuse sweating in the 
endeavor to abort colds. Alcohol has good and satisfactory 
action in meeting this indication, but probably it will be found 
that other drugs, such as camphor and, perhaps, nitroglycerin, 
will act as well. 

Large doses of alcohol have been much used in poisoning, 
especially in snake poisoning, but there is no need for such 
treatment. 

We may sum up the internal therapeutic uses of alcohol as 
follows: Alcohol is not a heart stimulant. It has no tonic 
action, and in large doses causes a patient to feel better by 
its strong narcotic effect. This feeling of betterment is often 
later followed by a depression of all vital activities, viz., there 
may be mental weariness, circulatory weakness, loss of appe- 
tite and impaired function of the internal secreting glands. In 
small doses it causes a feeling of rest when one is tired and 
over- worked, both by its sedative action and by its equally 
distributing the blood over the surface of the body. For such 
an effect alcohol should be taken only when physical and 



244 THE PRINCIPLES OF THERAPEUTICS 

mental labors are over for the day. The prohibitionists, 
however, have deprived the individual of his right to decide 
that alcohol is the sedative that he will have, and the question 
will arise as to whether being deprived of that sedative, he will 
not take other means to cause a feeling of well-being and rest- 
fulness. Will he take drugs (not necessarily narcotics, which 
he cannot get), but such drugs as coal-tar products and more 
aspirin? Or will he, instead of resting from his tire, re-stimulate 
wdth coffee and tea? Or will he brace up and depress at one 
and the same time by the excessive use of tobacco? This 
all remains to be seen. Alcohol as a drug is only rarely needed 
in the treatment of disease, and then, as just stated, only in 
small amounts and for a short time, much as a physician would 
use any other narcotic or circulatory depressant drug. 

Nitrites. — Nitrites are the most active vaso-dilator drugs 
that we possess, and in active soluble preparation they will 
always lower the blood-pressure. They vary only in the 
rapidity of their action. Those that act the most rapidly are 
the ones that should be used when vaso-dilatation and a 
change of the circulation is desired immediately; those of 
slower action are the ones that should be used when a less 
rapid and a more prolonged fall of blood-pressure is desired. 

Amyl Nitrite occurs as a clear or yellowish liquid of ethereal, 
pungent odor and aromatic taste. It is very volatile, and must 
be kept in a dark, cool place, and in glass-stoppered bottles. It 
is better prepared and kept for administration in ampules. The 
dose is 0.2 mil (3 minims) by inhalation. The best method of 
administering this drug is by crushing a glass ampule of it in a 
handkerchief and then holding the handkerchief close to the 
nostrils for rapid inhalation. 

Nitroglycerin is official only as the Spiritus Glycerylis Nitratis. 
This spirit of nitroglycerin (spirit of glonoin) contains 1 per 
cent, of nitroglycerin. It is a clear, colorless, alcoholic liquid, 
and should be kept in a cool dark place in a well stoppered 
bottle. The dose of this preparation is 0.05 mil (about 1 
minim) . Generally, nitroglycerin is much better administered 
as a soluble tablet, and the average dose is 3^ 00 grain, but the 
range of dose is from J-500 to }io grain. 



NITRITES 245 

Sodium Nitrite occurs in white masses or as a granular 
powder, is very soluble in water, and the dose is 0.06 Gm. 
(1 grain). This preparation is slightly irritant to the stomach, 
but otherwse it has a similar action to nitroglycerin. 

Erythrol Tetranitrate, N.N.R. — This is a solid preparation 
which is best dispensed in ready-prepared tablets. It acts 
like nitroglycerin, only its activity is slower and more lasting, 
the action beginning in about fifteen minutes and lasting 
three or four hours. The dose is 0.03 to 0.06 Gm. (% to 1 
grain). 

Action. — Amyl nitrite is slightly irritant to mucous mem- 
branes. Sodium nitrite is also irritant and may disturb the 
stomach, if it is empty. Tablets of nitroglycerin and of ery- 
throl tetranitrate are non-irritant. 

The action from amyl nitrite when administered by inhalation 
is almost instantaneous, and this action is entirely on the 
circulation. A nitroglycerin tablet dissolved in the mouth or 
given hypodermatically acts also very rapidly. When taken 
on an empty stomach it will be rapidly absorbed; on a full 
stomach it will be more slowly absorbed. The same is true of 
erythrol tetranitrate. Sodium nitrite should never be adminis- 
tered on an empty stomach. 

The first activity of a nitrite is that of causing peripheral 
dilatation, a feeling of fullness in the head, throbbing of the blood- 
vessels, especially in the neck, head and forehead, sometimes 
flushing of the face, and headache, if the dose is sufficient to 
cause much dilatation. The heart is temporarily made more 
rapid. The length of time that the vaso-dilatation lasts varies 
from about half an hour to three or four hours. Although in the 
laboratory the action of nitrites has been proved to be so rapidly 
over, still clinically a fall of blood-pressure that lasts even a 
short time is of benefit to an individual who needs such treat- 
ment, and the value of nitroglycerin for patients with symptoms 
of high pressure such as heart pains and high tension headache 
is great. Part of the blood-pressure fall may be due to a de- 
pressant action on the vaso-motor centers and part may be due 
to actual dilator action on the blood-vessel walls. With com- 
plete action of a nitrite the veins are also somewhat dilated. 



246 THE PRINCIPLES OF THERAPEUTICS 

From these activities the blood-pressure will decidedly fall 
under the action of nitrites. 

If cardiac pain is due to high pressure, or to coronary disease, 
it may be relieved by the relaxing dilating effect of a nitrite on 
the general circulation, and an anginal pain will often be imme- 
diately relieved by inhalation of amyl nitrite. Nitrites have no 
action in the body except that caused locally by a change in 
circulation, therefore the action on the brain is due to the cir- 
culatory changes. Nitrites are oxidized into nitrates, and are 
thus excreted in the urine. 

Over-action. — The symptoms of over-action are headache, 
full-headedness, dizziness, and perhaps syncope. On account 
of amyl nitrite so readily causing such a condition, it is rarely 
used except for emergencies. 

Severe poisoning can hardly occur clinically from a nitrite. 
The most serious symptoms that can occur from too large a dose 
of a nitrite is heart weakness, cyanosis, and coldness of the ex- 
tremities. The treatment would be to give quick-acting vaso- 
constricting drugs, such as the active principle of the posterior 
lobe of the pituitary gland, epinephrine, strychnine, atropine 
and caffeine. 

Uses. — The emergencies in which a quick-acting nitrite is 
needed are angina pectoris and epilepsy. A patient who has 
anginal attacks should always carry soluble nitroglycerin tab- 
lets in his pocket, each Jioo of a grain, to dissolve quickly in 
his mouth whenever he has an attack. If one tablet is not 
sufficient, in ten minutes he should take another one, and this 
may again be repeated, the only limit being the throbbing in the 
head, especially in the forehead, and a full-headed feeling. If 
deemed best, he may also carry ampules of nitrite of amyl. The 
quicker action of the nitrite of amyl when an ampule is crushed 
in the handkerchief and inhaled is generally reserved for an 
aura of an epileptic attack. An epileptic who has an aura long 
enough for him to crush such an ampule and inhale it may 
prevent the fit. 

The only other emergency use of a nitrite is in asthma, al- 
though the emergency is not so urgent. Such a patient may 
also dissolve nitroglycerin tablets in his mouth and get quick 



DRUGS ACTING ON THE CENTRAL NERVOUS SYSTEM 247 

relaxing results. He should be instructed to dissolve a J^oo 
grain tablet under his tongue, and repeat it every half hour until 
he obtains relief. 

When it is decided to lower blood-pressure with nitroglycerin 
the choice is generally nitroglycerin or erythrol tetranitrate 
tablets. The frequency of the dose depends upon the effect on 
the individual, but generally four times in twenty -four hours is 
sufficient, a tablet after each meal and on going to bed. For this 
vaso-dilating effect the tablet should not be dissolved in the 
mouth, but should always be taken with plenty of water, and 
preferably when something is in the stomach. In other words, 
rapid action is not desired, and the disagreeable pressure feel- 
ings in the head need not be caused. 

Symptoms of high pressure such as dizziness, a feeling of 
tension in the head, occipital headache, and cardiac ache, and 
possibly cold hands and feet, may be relieved many times by a 
small dose of nitroglycerin, as 3^oo to }ioo grain, when a larger 
dose, as }ioo grain may cause headache; but the dose depends 
on the individual. It is rarely necessary, however, to give 
more than ^loo of a grain, although that dose may be needed 
every three or four hours. 

As stated under the subject of alcohol, in high fever, when 
apparently alcohol is indicated, nitroglycerin may act as well to 
dilate the peripheral blood-vessels and promote perspiration. 

In spasmodic conditions such as occur in dysmenorrhea, at 
times vaso-dilatation from nitroglycerin may cause relief. 

In insomnia from high pressure a dose of nitroglycerin taken 
with a cup of malted milk at bedtime will often promote sleep. 

In attacks of asthma nitroglycerin will generally cause 
immediate relief. If the blood-pressure is low, however, and 
there is venous congestion and cardiac weakness, epinephrine 
on the tongue will often act more satisfactorily. 

CLASS V 
Drugs used for action on the Central Nervous System 

This class includes drugs which have a very slight effect on 
the brain and spinal cord and drugs that have a profound effect 



248 THE PRINCIPLES OF THERAPEUTICS 

on the central nervous system, as anesthetics. Their action 
can only well be discussed in their separate sub-classes. 

DRUGS USED TO STIMULATE THE BRAIN AND SPINAL CORD 

The once called " antispasmodics " are drugs that seem to 
modify hyper-excitability and prevent various pseudo-spasmodic 
conditions and relax pain. These drugs are not narcotics, but 
cause improvement by stimulating the higher brain centers of 
control, actually as by camphor perhaps, or suggestively as by 
the disagreeable odor of the long used asafetida and valerian. 
These last named drugs may aid nervous control in hysteria by 
the psychic effect of the smell, or if in alcoholic preparations, 
may cause sufficient alcoholic cerebral effect to quiet the patient. 
Spirit of lavender has been much lauded for hysteria, but it 
is the alcohol only that is effective. 

These drugs, namely, asafetida, valerian and lavender, at 
times so valuable in hysteria, are often less effective than is so- 
called "Christian Science." 

Camphor is really a cerebral stimulant and dilates the 
peripheral blood-vessels, and may change the view-point of 
the hysteric. However, before hysteria is diagnosed as an en- 
tity in a given case, all other more tangible conditions must be 
excluded. There is generally a cause for these disturbed im- 
pulses, often an endocrine gland dysfunction. The thyroid 
gland is the one most generally in trouble, and frequently the 
ovarian function is abnormal. 

Thyroid gland extracts are cerebral stimulants, especially 
in conditions that need such stimulation. The value of caffeine 
and atropine as circulatory stimulants has been discussed. 
They are also cerebral stimulants, the caffeine especially stimu- 
lating brain activity, and atropine especially stimulating the 
medullary centers and in large doses causing cerebral excite- 
ment. Strychnine is not only a medullary stimulant, but is 
especially a spinal motor stimulant. The discussion of the use 
of these drugs, caffeine, atropine, and strychnine as nervous 
stimulants would take us into the discussion of the treatment 
of shock, coma, and paralysis. Suffice it to say under this 
caption that none of these drugs should be used in nervous 



DRUGS TO STIMULATE BRAIN AND SPINAL CORD 249 

irritability or in sleeplessness, and that coffee and tea are often 
the cause of insomnia. 

Belladonna. — Belladonna is official both as the leaves and 
the root, but as all activities of belladonna are those of atro- 
pine, as far as its therapeutic use is concerned, there is no need 
for the preparations of this drug for internal use; We do not 
need the extract, the tincture, or the rluidextract of belladonna. 
The official belladonna plaster which represents 20 per cent, of 
the drug, and the official ointment of belladonna which repre- 
sents 10 per cent, of the drug are useful preparations for ex- 
ternal use. The official liniment of belladonna is superfluous, 
as the absorption of atropine could not be limited and poisoning 
might be caused. 

The only use for belladonna externally is as a sedative to 
relieve pain and irritation. In susceptible individuals, even 
the belladonna plaster may cause poisoning, and the belladonna 
ointment should, also, not be used in a large amount at any one 
time. 

Hyoscyamus. — There seems to be no good reason why this 
drug should be used as such or in its three official preparations. 
The tincture of hyoscyamus has been long used as a sedative, 
more especially in irritable conditions of the bladder, and in 
pelvic disturbances. There is no proof that there is an activity 
of this drug other than that of atropine. Its atropine-like 
alkaloid is termed hyoscyamine, but this alkaloid, unlike atropine, 
when used alone is likely to cause secondary depression. The 
other alkaloid of hyoscyamus, scopolamine (hyoscine) besides 
having a primary atropine action has a sedative action on the 
central nervous system; this alkaloid is used only as a hypnotic. 

Hyoscyamine is official as Hyoscyamine^ Hydrobromidum, 
but as this drug is likely to cause unexpected depression, there 
seems to be no justification for its use. 

Scopolamines Hydrobromidum (hyoscine hydrobromide) is 
very soluble in water, and is used principally hypodermatically 
in intense cerebral excitement, in acute delirium, and in the 
sleeplessness of insanity. When given hypodermatically, or 
in a tablet to be dissolved in the mouth, it generally quickly 
causes sleep. However, when there is an idiosyncrasy to 



25O THE PRINCIPLES OF THERAPEUTICS 

atropines, it may cause considerable cerebral excitement. Con- 
sequently, before giving a full dose of this drug, it should be 
ascertained that the patient is not susceptible to atropine. 
After a sleep from scopolamine there is likely to be consider- 
able circulatory depression. Consequently, it is not wise to 
give scopolamine as a hypnotic and then allow the patient to 
be up and about the next morning. 

Scopolamine has also been used in spinal irritability, and in 
paralysis agitans. The dose for these purposes is smaller, not 
sufficient to produce sleep, and it should be administered two or 
three times a day. In such patients a tolerance has sometimes 
been developed, and larger doses may be needed. 

Although scopolamine may cause atropine stimulation, it 
should never be considered that it is anything but a depres- 
sant, and when serious poisoning occurs, depression must be 
combated. 

The average dose is 0.0003 Gm. (Koo grain). It is often 
necessary, however, to give double this dose, Hoo of a grain. 

Stramonium is official as the leaves. The action of this drug 
is only that of atropine, and therefore there is no good excuse 
for its four official preparations. The action and poisoning of 
stramonium is that of an atropine. 

The only use for stramonium is in the form of the leaves, to 
be made into cigarettes or pastilles, or to be burned as a powder, 
for inhalation in asthma. Generally the leaves are combined 
with nitrate of potassium (saltpetre) which causes the drug to 
burn rapidly, and also gives some relaxation from the nitrite 
formed when the fumes are inhaled. The action of stramonium 
when inhaled is that of a sedative from the action of the atropine 
on the nerves of the mucous membrane of the air passages. 
Although inhaling this fume of atropine may give local sedative 
action to irritated nerve terminals in the region that is spasmod- 
ically contracted, still atropine sulphate given hypodermatically 
or dissolved in the mouth may cause the same satisfactory 
effect. 

Atropine. — Administration. — This drug is best used in the 
form of the official sulphate, which occurs as a white powder, 
very soluble in water. The dose varies from 0.0003 to 0.0006 



ATROPINE 251 

Gm. (Hoo to Hoo grain). In particular conditions, for specific 
purposes, much larger doses may be given. Although more or 
less rapidly absorbed, the full effects of the drug do not occur 
until after several hours, the length of time of course depending 
upon the mode of administration. Also the drug is slow of 
excretion and its action is therefore prolonged, hence atropine 
for any purpose should not be frequently repeated, rarely more 
than once in six hours, and then only for a few doses, unless the 
dose administered is very small. 

Action. — Atropine more or less inhibits all secretions, and 
therefore may tend to inhibit the gastric secretion, and for this 
reason has been used much for hyperacidity. For this purpose, 
however, its use is not a success. It dulls the peripheral endings 
of the nerves and therefore decreases intestinal irritability, and 
for this purpose it is often combined with laxatives with the 
object of preventing bowel cramps. 

After absorption it dries all secretions, especially those of the 
nose, throat, mouth, and bronchial tubes. It also decreases 
perspiration. It is a most active stimulant to the respiratory 
center, more or less accelerates the pulse, somewhat raises the 
blood-pressure by stimulation of the vasomotor center, and 
somewhat constricts the blood-vessels of the splanchnic region. 
At the same time it causes dilatation of some of the surface 
vessels, more especially of the face and the upper part of the 
body, and hence often causes flushing, and even a scarlatini- 
form eruption. 

If applied locally to the eyes, or if absorbed in any con- 
siderable amount, it causes dilatation of the pupils, and when 
applied locally to the eye in strong solutions (the strength most 
used for this purpose being 1 per cent.) it causes paralysis of 
accommodation. Atropine may be more or less absorbed from 
the skin and cause dulling of- the peripheral nerves and cessation 
of peripheral pain. It is excreted mostly in the urine, and per- 
haps may be excreted in the milk of nursing women. 

Over-action. — More individuals are susceptible to, and show an 
diosyncrasy against, atropine in any form than to any other 
one drug; some individuals, have an excessive action from 
the drug even from small doses. Besides the scarlatiniform 



252 THE PRINCIPLES OF THERAPEUTICS 

efflorescence on the face and upper part qi the body, there is 
dilatation of the pupils, very much drying of the throat and 
mouth, and at times a tachycardia occurs, from paralysis of 
the vagus endings in the heart. There is often also considerable 
cerebral excitation. This is especially noticeable in some in- 
dividuals when scopolamine is given to cause sleep. 

Toxic Action. — Convulsions may be caused by a poisonous 
dose of atropine, and death occurs from both respiratory and 
cardiac failure. 

Treatment of Poisoning. — The treatment is, of course, to 
prevent further absorption of the drug, by emetics if the drug is 
in the stomach, and by catharsis if it is presumed that it is in 
the intestine. Administration of morphine may aid in pre- 
venting the toxic effect of atropine and in quieting excitation. 
Large amounts of water should be drunk, and the bladder should 
be frequently catheterized, if the patient cannot pass urine 
freely. Means to promote perspiration are of value. 

Uses. — The indications for the use of atropine are: 

1. To inhibit or dull peripheral nerve irritation and hyper- 
excitability. 

2. To dry up secretions. 

3. To stimulate the heart and raise the blood-pressure. 

4. To stimulate the brain and nervous centers, especially the 
respiratory center. 

5. To stimulate smooth muscle tissue. 

6. To dilate the pupil and paralyze the accommodation. 

7. As an antidote in poisoning. 

1. For neuralgia atropine may be given internally, or may be 
used locally in the form of the belladonna plaster. If given in- 
ternally, the dose should be sufficient to cause some physiologic 
activity. It is very valuable in spasm of muscles caused by 
irritability of the nerves, or when such contractions are due to 
inflammation. For this purpose it is added to morphine when 
the latter is administered hypodermatically for hepatic and 
renal colic. When these drugs are used in combination, more 
relaxation of these muscular tubes is caused. It has been lately 
shown that benzyl benzoate will cause the relaxation which is 



ATROPINE 253 

aimed at with atropine, and at the same time it is a sedative 
similar to morphine. 

Atropine is frequently added (often as the extract of bella- 
donna, but just as valuable are the salts of the alkaloid) to 
laxative drugs to prevent intestinal cramp or intestinal colic 
from the latter. It is also given hypodermatically in various 
forms of intestinal colic and in lead colic. It is at times of 
value in spastic intestinal conditions of infants, when there is 
vomiting, bowel and stomach cramps, and a hyper-peristalsis. 
The dose for infants is very small, perhaps Ho 00 of a grain, but 
even in such small doses it seems to relieve some of this intesti- 
nal irritability. 

Atropine is one of the most used drugs in asthma, generally 
administered, however, during the paroxysm by inhalation from 
burning stramonium leaves. It was long used in whooping 
cough to modify and decrease the frequency of the paroxysms, 
and for this purpose it must be pushed to the point of slight 
intoxication. Antipyrine is, however, a better treatment for 
this disease. 

Atropine is often efficient in bladder irritability when there 
is too frequent urination, and is even valuable in cystitis, giving 
considerable relief while other treatments are being carried out. 
In large doses it is also frequently used for incontinence of 
urine, and is valuable when such is due to abnormal irritability 
of the neck of the bladder, and it also seems to increase the 
tone of the bladder sphincter. The dose must be large, and 
should be given at night. It may be found that pituitary ex- 
tracts are more valuable in this condition. As atropine is only 
a symptomatic treatment for incontinence of urine, the cause 
of such a condition must be removed, if such can be found. 
For irritability of the bladder in men who have enlarged pros- 
tates, atropine should ordinarily not be given, as it tends to so 
dull the sensibility of the bladder as to allow over-distention. 

2. There is no drug that equals atropine for drying up secre- 
tions, especially the perspiration, nasal, pharyngeal, and bron- 
chial secretions. It is largely used to inhibit the profuse sweats 
of tuberculosis; the dose should be good sized, and given at 
bedtime. 



2 54 THE PRINCIPLES OF THERAPEUTICS 

Atropine is often successful in aborting an acute cold. The 
dose should be 3^oo oi a grain every two or three hours for ten 
doses. It is often well to begin with a dose every hour until 
three doses have been taken, and then give the subsequent doses 
at three-hour intervals. By the time ten doses have been taken, 
if the cold has not been aborted, other treatment, to relax tissues 
and allow secretion, is indicated. The value of the various 
combinations termed " rhinitis tablets" is due to the atropine 
which they contain. The doses of the other ingredients are 
too small for activity; it is the atropine that is of benefit. 

Atropine is of value in salivation and in profuse bronchorrhea, 
and in increased nasal secretion; but the cause of these condi- 
tions must be sought, as this treatment is purely symptomatic. 
Many times infection in the nose or adjacent sinuses, or in the 
tonsils, teeth, or gums will be found. 

Atropine internally, or in the form of the belladonna oint- 
ment applied externally over the breasts, has been used to 
check lactation and acute inflammation of the breasts. 

3. In all conditions of shock, and when the heart is slow and 
weak, and the blood-pressure low, atropine, given hypodermatic- 
ally, is one of the best stimulants. The dose should be suf- 
ficient, but not too large, and not to be soon repeated. 34 00 °f 
a grain is the average dose. 

Atropine in much larger doses, pushed to the limit of phy- 
siologic activity is used in heart-block to differentiate between 
functional disturbance and disease of the bundle of His. It 
will cause a slow heart to become rapid if the disease is not 
Stokes-Adams disease. 

4. While atropine many times unexpectedly, and when such 
action is not desired, stimulates the brain to excitement, it is 
rarely used for that purpose. It is, however, frequently used 
in depressed conditions, to stimulate the medullary centers, 
especially the respiratory and vasomotor centers, and as a 
respiratory stimulant it is one of the most active of drugs. 

5. As a muscle stimulant atropine has long been used in 
bladder insufficiency, and in paralysis of the bowels, and has 
often been used in large doses in paresis of the intestines after 
operation. It is, however, not as valuable for these purposes 



ATROPINE 255 

as is pituitary extract, ergot, or tyramine. In intussusception, 
or in twisting of the bowel and a spastic condition, the con- 
tracted region may be relaxed by large doses of atropine, 
provided it is safe to wait for the test before surgical cure is 
attempted. 

6. Atropine is in daily use to dilate the pupils. It is not 
used in every eye examination, and is used rarely by some 
oculists for eye tests at the present time, other tests being 
relied upon. However, generally, more accurate tests can be 
made with the complete paralysis of accommodation that occurs 
from full doses of atropine. Too careful tests cannot be made 
to decide upon the amount of astigmatism that is present and 
to decide exactly what the optical defects of an eye are, hence 
every aid to develop the right decision must be used. Time 
is no object. It is a question of comfort, perhaps health, and 
certainly of money to the individual. Too many wrong 
glasses are given; too frequently they are mal-ad justed; and too 
frequently does the individual become a burden to himself or 
herself, to the family, and to the physician because one or 
more oculists or opticians do not do their best. Atropine 
should not be used in the eyes, ordinarily, when the individual 
is over forty. 

Homatropine is more frequently used than atropine, because 
the effects are over in from thirty-six to forty-eight hours; 
but the paralysis of the accommodation from homatropine is 
not as complete as that from atropine. Unfortunately, the 
accommodation does not return to normal after the full local 
action of atropine until a week or more. For an eye test 
a 1 per cent, solution is generally used. 

As a sedative to the eye in various inflammations, atropine 
has no equal. From 0.5 to 1 per cent, solutions may be used 
several times a day, as deemed advisable. Atropine should not, 
however, be used in the eye after a patient is much over forty, 
lest it cause increased tension by dilating the iris so as to block 
the canal of Schlemm and thus increase the ocular tension; and 
after forty-five there is always danger of causing glaucoma, and 
atropine should never be used in glaucoma. 

To cause contraction of the pupil and reduce ocular pressure 



256 THE PRINCIPLES OF THERAPEUTICS 

in glaucoma and inflammation of the eye after iridectomy, and 
in some corneal ulcerations, eserine is used. 

Physostigmina Salicylas (eserine salicylate) is an alkaloid 
obtained from physostigma (calabar bean) . This salt occurs as 
colorless or faintly yellowish crystals, which are soluble in 
considerable water. It is used locally to contract the pupil 
in 0.3 per cent, solution (3-1,000). 

7. As an antidote in all depressant drug poisonings atropine 
has no equal. It is also of great value in poisoning by mush- 
rooms, as it is antagonistic to muscarine poisoning. It is also 
an antidote to the depression from toxins developed or 
absorbed from the intestine. In morphine poisoning, although 
atropine is somewhat of an antidote, it should not be used in a 
large amount, as very large doses of atropine will depress the 
respiratory center as does the morphine. Consequently, 
atropine is not a very good treatment in morphine poisoning, 
although when a large dose of morphine must be administered 
it is well combined with atropine to prevent too profound an 
action of the morphine on the respiratory center. 

HomatropifKE Hydrobromidum (hydrobromide of homatro- 
pine) is an alkaloid obtained by the condensation of tr opine 
and mandelic acid. It occurs as a white crystalline powder or 
as prisms, is soluble in water, and is used in about a 1 per cent, 
solution to dilate the pupil and paralyze the accommodation. 

Camphor. — Administration. — Camphor occurs in white trans- 
lucent masses or granules, has a pungent, characteristic odor, 
and a pungent, aromatic taste. It is very soluble in alcohol, 
but slightly soluble in water. The dose is 0.20 Gm. (3 grains) 
by the mouth, and hypodermatically, in solutions in aseptic 
oil, the dose is 0.10 to 0.20 Gm. {}^ to 3 grains). For hypo- 
dermatic use the solutions may be prepared extemporaneously, 
but sterile ampules may be obtained. 

The preparations used for camphor action are Aqua Cam- 
phors and Spiritus Camphors. The dose of the camphor 
water is from 1 to 3 teaspoonfuls. The dose of the spirit of 
camphor is 1 mil (15 minims). 

Action. — On the surface of the body it is slightly irritant and 
astringent, and if rubbed on the skin may cause some reddening 



DRUGS TO DEPRESS THE BRAIN AND SPINAL CORD 257 

and a slight anesthetic effect. In strong preparations, on 
mucous membranes, it is somewhat irritant, and when taken 
internally it should be well diluted. It is rapidly absorbed, and 
is stimulant to the brain and cerebral centers, especially to the 
respiratory center. It may slightly stimulate the vasomotor 
center, but tends to dilate the peripheral blood-vessels and cause 
a general feeling of warmth to the body. It also frequently seems 
to stimulate the heart, especially in collapse and depression. 

Over-action. — It is difficult to cause poisoning in the human 
being unless the amount administered is excessive, and then 
respiratory depression and convulsions might be caused. Ordi- 
nary full dosage could have no effect except that of slight cerebral 
excitement, and possibly flashing and increased perspiration. 

Uses. — The most important use of camphor is intramuscu- 
larly in aseptic oil, for stimulation purposes in shock and circu- 
latory depression. While some laboratory reports and some 
hospital reports show that camphor fails in these conditions, 
clinically, those who use camphor most for such purposes are 
sure that it is a stimulant of no mean value. It has long been 
used for the depression following chloroform anesthesia, and 
apparently inhibits depression from that anesthetic. There 
is no question that many times camphor, given subcutaneously 
or intramuscularly or by mouth is of value in collapsed condi- 
tions, in conditions of cold skin and chilliness, and in some con- 
ditions of mental depression. It may be administered (ampules 
contain 2 or 3 grains), subcutaneously, every hour for two or 
three doses, and then less frequently. By the mouth it may be 
given every hour for a series of doses, and then less frequently. 

Camphor has a valuable carminative action, and may be 
combined in various methods to promote intestinal action and 
relieve gas pains. Whether administered with hot drinks, as 
hot lemonade or tea, or when combined with opium or mor- 
phine, its action in causing perspiration and in modifying the 
congestion in fresh colds is often satisfactory. 

DRUGS USED TO DEPRESS THE BRAIN AND SPINAL CORD 

Some drugs of this class have been termed "depressomotors" 

such as bromide, chloral, gelsemium, physostigma, etc., in 
17 



258 THE PRINCIPLES OF THERAPEUTICS 

contradistinction to those drugs that excite motor activity. 
The drugs of this class are indicated in increased and excessive 
nervous irritability, in muscle spasms, and in convulsions. 
These drugs are all more or less circulatory depressants, hence 
must be used with care in cardiac weakness. Also, the after 
effect of all of them is that of general depression, if the doses are 
large. 

Many drugs of this class are used for other purposes and 
depress the central nervous system secondarily; for example, 
acetanilid, antipyrine, phenacetin and aspirin are used as 
antipyretics and to stop subacute pain and aches, but seconda- 
rily they more or less depress the brain and spinal cord, aspirin 
the least. Gelsemium has long been used to stop peripheral 
nerve pain, but not so frequently since the coal-tar drugs 
became so much in vogue. Lately the drug most used as an 
anti-neuralgic, anti-cold, and anti-most anything is aspirin 
(acetylsalicylic acid). This drug is used too much, and often 
causes some cardiac depression. Physostigma (calabar bean) 
and its alkaloids are too uncertain in their action, also too 
likely to cause serious depression, and hence should not be used 
internally. 

The best and most active cerebrospinal depressants are 
bromides and chloral, and these drugs are indicated in cerebral 
excitement, in spinal irritation, and in strychnine poisoning. 
They are also used in tetanus. Morphine is a cerebral de- 
pressant, but primarily a spinal excitant, although large doses 
stop spinal irritation and convulsions by its stupefying action 
on the cerebrum. 

Gelsemium. — Administration. — Gelsemium is official as the 
rhizome and roots, but is not used as such, but in one of its offi- 
cial preparations, the best of which are the Fluidextr actum 
Gelsemii and Tinctura Gelsemii. The dose of the fluidextract 
is 0.03 mil (}i minim) ; the dose of the tincture, which represents 
10 per cent, of the drug, is 0.25 mil (4 minims). 

Action. — Briefly, the action of this drug is, in ordinary dosage, 
mildly depressant; it lowers the blood-pressure, slows the heart 
and depresses the irritability of the spinal cord and nerves, both 
motor and sensory. It may cause, in larger doses, some dilata- 



DRUGS USED TO STOP PAIN 259 

tion of the pupil. It lowers the temperature somewhat by 
slowing the circulation, dilating the peripheral vessels, and 
slowing general metabolism. If the patient has fever, it will 
cause some perspiration. It is excreted rather rapidly by the 
kidneys. 

Over -action, — In over-action from this drug the pulse is 
feeble, the skin cold, and the patient feels faint. Besides dilata- 
tion of the pupils, there may be some paralysis of the upper 
eyelids. 

Toxic Action. — The toxic action is, in a word, that of depres- 
sion with shock, and death is caused by failure of the respiration. 

Treatment of Poisoning. — Vomiting should be caused if it is 
supposed that the stomach contains the poison, after which the 
treatment is circulatory and nervous stimulation with strych- 
nine, atropine, digitalis, and pituitary extracts ; dry heat to the 
body; and artificial respiration, if needed. 

Uses. — The only logical use at the present time for gelsemium 
is as a sedative in peripheral neuralgias. It seems to be espe- 
cially efficient, at times, in neuralgia of the fifth nerve, head- 
aches, intercostal neuralgia, and sometimes in sciatica. How- 
ever, this drug has given place to the coal-tar products which 
are much more frequently used as anti-neuralgics. Also, more 
care is now taken to ascertain the cause of the neuralgia, and 
there generally is a definite cause. The cause being found and 
removed, the neuralgia ceases. Various local applications of 
heat or electricity in some form are better treatments of neu- 
ralgia than drugs. If the peripheral pain is caused by central 
disturbances, as locomotor ataxia for instance, gelsemium is of 
little value, and would rarely stop that kind of nerve pain, 
unless the dose was exceedingly large. Non-irritant solutions, 
as about i^ per cent, of gelsemine in water, dropped into the 
eye will dilate the pupil by paralyzing the endings of the oculo- 
motor nerve. 

DRUGS USED TO STOP PAIN 

The drugs of the previous class will stop aches and subacute 
pain, but acute, severe pain can be stopped only by the anes- 
thetic action of ether or chloroform, or by opium or one of its 
alkaloids. Acute pain must be stopped, and chronic pain can- 



260 THE PRINCIPLES OF THERAPEUTICS 

not be long endured without causing depression of all vital 
functions. The acute pain of renal or hepatic colic may require 
partial chloroform anesthesia until the injected morphine can 
begin to act. Or chloroform may be advisable in such a con- 
dition in order not to give a poisonous or dangerous dose of 
morphine. 

Opium. — Administration. — The Pharmacopoeia recognizes as 
opium the milky exudate of the unripe capsules of papaver 
somniferum. Preparations made from this substance are the 
ones used in medicine. The official preparations are as follows : 

Opii Pulvis, powdered opium; dose 0.06 Gm. (1 grain). 

Opium Deodoratum, deodorized opium; dose 0.06 Gm. (1 
grain). 

Opium Granulatum; dose 0.06 Gm. (1 grain). 

Extr actum Opii (a powdered extract); dose 0.03 Gm. (X£ 
grain). 

Pulvis Ipecacuanha et Opii, Dover's powder; dose 0.50 Gm. 
(7M grains). This preparation contains 10 per cent, of ipecac 
and 10 per cent, of opium. 

Tinctura Opii, laudanum, (10 per cent, strength) ; dose 0.5 mil 
(7^ minims). 

Tinctura Opii Camphorata (paregoric) contains 0.4 per cent, 
each of opium and of camphor; dose 5 mils (a teaspoonful) . 

Tinctura Opii Deodorati, tincture of deodorized opium, (10 
per cent, strength); dose 0.5 mil (7^ minims). 

Opium contains many alkaloids, the most important of which 
are morphine and codeine. The official preparations of mor- 
phine are: 

Morphince Eydrochloridum, which occurs as a white crystal- 
line powder, very soluble in water, the dose of which is 0.008 
Gm. {% grain), and 

Morphince Sulphas which occurs as white feathery crystals, 
very soluble in water, the dose of which is 0.008 Gm. (J£ grain). 

Codeine is official in the form of Codeince Phosphas, which 
occurs as fine, white crystals, very soluble in water, the dose of 
which is 0.03 Gm. (J^ grain), and Codeince Sulphas, which occurs 
in white crystals, very soluble in water, the dose of which is 0.03 
Gm. {V 2 grain). 



OPIUM 26l 

An artificial alkaloid is formed from morphine, termed 
heroin, which is recognized in the Pharmacopoeia as Diace- 
tylmorphincB Hydrochloridum, which occurs as a white crystal- 
line powder, very soluble in water, the dose of which is 0.003 
Gm. (3^20 grain) . There is no advantage of this drug over code- 
ine. It is very subtle in its ability to cause a habit, and it has no 
activities whatsoever of any advantage over codeine. The drug 
should be abolished. 

Another preparation formed artificially from morphine is 
dionin which is official under the name of Mthylmorphina 
Hydrochloridum. This drug also is not needed. 

A new synthetic has recently been prepared by Macht termed 
Benzyl Benzoate. This preparation apparently has the advantage 
of stopping spasm and pain, and of relaxing muscle tubes, with- 
out being actively narcotic, and it does not apparently tend to 
cause a habit. This new drug seems to be specifically of value 
in colics and muscle spasms, and seems to be useful in such 
conditions as spasmodic dysmenorrhea, certain forms of asthma, 
and probably will be found of value in many conditions of 
hypertonicity and muscle irritability. The advantage of this 
new preparation over morphine is because morphine alone 
tends to cause contraction of smooth muscle tissue. This of 
course may not be in evidence when very large doses are given, 
or when morphine is combined with atropine to allay peripheral 
irritation that may be causing the colic, and of course large 
doses of morphine will cause general relaxation of all tissues. 
Nevertheless, this new drug is a great addition to useful drugs, 
as it will relax spasm and quiet pain without the unpleasant, 
disagreeable, and often dangerous narcotic effects of morphine 
and codeine or some other form of opium. This drug can be 
given repeatedly, apparently, without the development of 
a habit. This alone is enough to put the drug in a high class. 

Benzyl benzoate is an ester of benzyl alcohol and benzoic 
acid. It is obtainable in the form of a solution termed "benzyl 
benzoate miscible, " each ten drops of which contains two drops 
of benzyl benzoate, the average dose of which is 25 to 30 drops, 
but a fmidrachm may be taken by adults without poisoning. 
In any form thus far offered this preparation is very disagreeable 



262 THE PRINCIPLES OF THERAPEUTICS 

to take. Therefore attempts have been made to offer it in 
an emulsion. It is best administered in milk. The dose ap- 
parently should be sufficient to stop the pain, and it has not 
been shown to cause any serious after effects. It has 
been used with considerable success in dysmenorrhea, in 
asthma, in whooping cough, in hiccup, in diarrhea, in intestinal 
colic, for the pains of mucous colitis, and it has seemed at times 
to lower blood-pressure. 

Action. — It is obvious that the action of opium would be that 
of its alkaloids, and its most important alkaloid is morphine, 
therefore the physiologic action after absorption is really the 
action of morphine. Opium is rapidly absorbed, especially 
when taken in liquid form on an empty stomach. In large 
doses it may cause nausea and vomiting, and the same is true 
of its alkaloid morphine. It inhibits the activity of the stom- 
ach and intestines, slowing or stopping peristalsis and diminish- 
ing the digestive secretions. If nausea and vomiting are caused 
it may increase the gastric secretion, especially of mucus, at 
the same time it increases the salivary secretion, probably due 
to the irritation of the vomiting center. 

The action of this drug and its alkaloid, even when given 
hypodermatically, causes loss of appetite and generally consti- 
pation. If, however, pain is reflexly inhibiting the action of 
the bowels, relief from the pain may allow movements to occur. 

After absorption it inhibits most secretions, especially the 
endocrine gland secretions, and particularly the suprarenal 
secretion. At times it may cause perspiration, especially if 
combined with some other drugs, such as ipecac or camphor, 
but at other times it causes the skin to be dry. 

Opium, and especially morphine, often more or less improves 
the heart tone, and often slows a rapid heart, and a weak heart 
is not made weaker unless the dose is large and there is pro- 
found effect from the drug on the respiratory center. The 
slowing of the heart is due to depression of the accelerator 
mechanism or to slight stimulation of the cardiac inhibitory 
center in the medulla, namely, the vagus center. There may 
be a slight increase in blood-pressure when the blood-pressure is 
low. Even fair sized doses of opium or morphine diminish the 



OPIUM 263 

irritability of the respiratory center and cause more or less 
slowing of respiration; large doses slow it very greatly. 

Morphine is primarily a stimulant to the spinal cord, and in 
animals will cause convulsions, while in the human being the 
action is so intense on the brain that the irritation of the spinal 
cord is overcome. After small doses there may be a slight stimu- 
lation of the cerebral centers, although there is a diminution 
of self-control, and the judgment may be impaired. In larger 
doses the effect is quieting and sleep-producing, except in some 
peculiar individuals who have an idiosyncrasy against any 
narcotic of the opium or morphine type. They are mentally 
excited, and may even have delirium, unless the dose is exceed- 
ingly large. The same condition is noted when there is cerebral 
inflammation or cerebral excitement, insanity, delirium tremens, 
etc., when a small dose will do nothing but excite the patient, 
and even a medium dose may not quiet him, and perhaps a 
dangerous dose would be required if this drug was the one to 
be used for sedative effect. Young children are very pro- 
foundly affected by opium in any form, perhaps because their 
brains are relatively so much larger than the brains of adults. 
At any rate, the dose of any opium narcotic must be very 
much smaller than the ordinary dose 'computed by age and 
weight. 

When sleep is caused by opium or morphine it is generally 
profound. The patient may be hard to arouse, the respiration 
becomes slow, the pulse slow and full, and the skin generally 
warm, provided the dose is not too large. 

There is no object in injecting a dose of morphine at the 
site of pain, as the action of the narcotic seems to be entirely 
central and the nerve endings are probably not acted upon by 
this drug. Some patients are sexually stimulated by the 
action of morphine and opium, unless the dose is large. 

Under the action of morphine or opium nitrogenous metab- 
olism is diminished, and with the decreased muscle activity 
and the sleep, there is decreased oxygenation and lessened 
excretion of carbon dioxide acid, i.e., metabolism is more or 
less at a standstill. Under the normal action of the drug the 
pupil is always contracted, due to action on the brain centers. 



264 THE PRINCIPLES OF THERAPEUTICS 

If the action is intense, the pupil will not dilate in darkness and 
will be pin-point in light. 

A large part of the drug is destroyed in the body by oxida- 
tion, but considerable of it is excreted in the urine and some 
into the stomach and intestines. Therefore in any over-action, 
the stomach must be washed out, a purgative given, and the 
bladder cathaterized. Under the action of morphine the 
bladder sensibility is so obtunded that it frequently becomes 
distended with urine, and then from partial paralysis is unable 
to expel the urine. Consequently, when morphine has been 
given, the patient must be aroused once in four or five hours 
and told to evacuate the bladder, unless the condition is such 
that a catheter must be passed. The excretion begins soon 
after the drug has been taken, but it may not all be excreted 
for many hours, and after repeated doses perhaps not for 
several days, although the habitue does not accumulate it. 

On account of the general inhibition of nerve and muscle 
activity the temperature is generally lowered, by morphine 
and, if the patient is narcotized by the drug, the surface of the 
body rapidly loses heat; consequently, in profound narcosis 
this must be prevented by the application of dry heat. Small 
doses of morphine may increase the output of urine; large doses 
will always diminish its amount, and glycosuria may rarely 
occur. 

Over-action. — Over-action from opium is evidenced by too 
profound sleep, too slow respiration, and profound narcosis. 
Such over-action may occur unexpectedly in some few indi- 
viduals, and is likely to occur when there is serious disease, 
as nephritis or cirrhosis of the liver. Undesirable action occurs 
in susceptible individuals who are unduly stimulated by opium 
in any form, some even having delirium. Such patients should 
not be given any form of opium, unless the indication is very 
unusual. To quiet such a patient requires an enormous dose, 
and many times a dose that is not safe. 

Undesirable after effects from morphine occur more or less 
frequently, such as nausea, faintness, depression, constipation, 
and such an obtundity of the bladder sensations as to allow it to 
become distended, and then more or less paralytic. This is a 



OPIUM 265 

very troublesome complication on account of the necessity for 
catheterization and the danger of infection. 

Toxic Action. — A very large dose of opium or morphine taken 
by the mouth may cause immediate vomiting, and the patient 
be thus saved from poisoning, while medium sized doses will 
be absorbed and cause poisoning. Of course a poisonous dose 
may be taken hypodermatically. The symptoms are profound 
sleep or absolute coma; very much slowed respiration; slow, full 
pulse; contracted pupils; the face may be flushed or congested, 
and if the respirations are very slow the patient is cyanotic. 
Death is caused by paralysis of the respiratory center. 

A patient found in coma calls for a very careful diagnosis 
of the condition. There may be an injury, in which case, 
generally, the pupils are either not contracted, or at least one 
may be contracted and the other dilated. There may be an 
apoplexy, in which condition one side of the body is generally 
more lax than the other side, and the face may be drawn to one 
side. The pupils in this condition may be irregular. In 
coma from alcohol or from wood alcohol the pupils will probably 
react to light, but there is, of course, the odor of alcohol on 
the breath; but the odor of alcohol on the breath is no indi- 
cation that the condition is due to a poisonous dose of alcohol. 
Diabetic coma may be determined by catheterization and 
analysis of the urine. A patient may be found stupid from 
uremic coma, but there is generally a history of convulsions, 
which some one may have seen. Analysis of the catheterized 
urine will help to make the diagnosis in this case. The pupils 
are also not as tightly contracted. Epileptic coma will give 
a history of preceding convulsions, with sometimes blood drool- 
ing from the mouth from a bitten tongue. In chloral poisoning 
with coma the pupils are dilated. In carbolic acid coma 
there are white eschars on the lips and mouth, and the odor of 
phenol. 

Treatment of Poisoning. — The indications for treatment are : 
(1) wash out the stomach, if the poison was swallowed; (2) 
administer such drugs as have some antidotal action on mor- 
phine and opium; (3) promote respiration; (4) prevent failure 
of the heart. 



266 THE PRINCIPLES OF THERAPEUTICS 

If a poisonous dose of opium has been taken only a few min- 
utes before the patient is seen, an ordinary emetic may act, but 
if the patient is under the influence of the narcotic, the emetic 
will not act, therefore the stomach must be washed out by 
means of the stomach tube. Tannic acid solutions are some- 
times used, or permanganate of potassium solutions, tannic acid 
forming more or less insoluble tannates, and the potassium 
permanganate decomposing the alkaloid, causing it to be more 
or less inert. Whatever is used, the stomach should be washed 
out until apparently clean. 

To meet the second indication, half a pint of strong coffee 
may be passed into the stomach and left there. Give atropine 
sulphate hypodermatically in a dose of Moo of a grain. Caffeine 
may also be given hypodermatically. 

To meet the third indication every means possible in the 
way of arousing the patient should be tried, but it is not advis- 
able to walk him around to the point of exhaustion, or to un- 
cover a patient too much for different skin stimulations or 
irritations, as in opium poisoning heat is lost rapidly, and many 
of the methods previously used to keep a patient awake have 
caused serious heart depression. Sometimes faradic electricity 
applications to different parts of the body act as one of the best 
stimulants. 

If the patient breathes very slowly, artificial respiration 
must be done. This may be kept up for hours. The pulmotor 
may be used, if it is deemed advisable. Artifical respiration 
should not be done too rapidly, twelve to fourteen respirations 
a minute being sufficient. 

Large doses of atropine should not be given, as the secondary 
effect of atropine is also to paralyze the respiratory center, 
therefore the single dose of Jfoo of a grain is generally sufficient, 
whatever the amount of the opium or morphine that was taken. 
If the respiration of the patient has not greatly improved in two 
or three hours, a second dose of }{qq of a grain might be given. 

To meet the fourth indication, the patient should be kept 
warm. A hypodermatic injection of )£o of a grain of the sul- 
phate of strychnine may be administered, which may be repeated 
in an hour. It is generally well to wash out the stomach again 



OPIUM 267 

in two or three hours, and also to catheterize the bladder, as the 
morphine is excreted in the stomach and also by the urine, and 
could be again re-absorbed, if it was not removed. Artificial 
respirations may be continued for hours, if necessary, and 
patients have been saved by such prolonged treatment 

Chronic Poisoning. — Chronic poisoning due to smoking opium 
is of rare occurrence in this country, but the habit of taking 
opium, morphine or heroin in some form, most frequently per- 
haps hypodermatically, is still of frequent occurrence, although 
under the action of the National law these drug addiction cases 
will gradually be eliminated. 

The symptoms caused by suddenly stopping morphine are 
always serious; the nervous irritability and excitement is some- 
times terrible. There may be vomiting; coughing; diarrhea; 
various forms of skin disturbances, itching of the skin; absolute 
inability to sleep ; and there may even be dangerous weakening 
of the heart. Hence, whatever the method used for overcom- 
ing the morphine habit, the patient must be under the constant 
supervision of a competent physician. The gradual method of 
stopping morphine is at times selected by the physician, and 
often is satisfactory where the patient has been receiving the 
drug for some acute illness and has acquired a partial habit. 
The drug in such cases may be gradually stopped without 
causing the patient to suffer. But a patient who really has 
acquired a habit cannot be cured at home in this manner, and if 
he is cured at home by the absolute stoppage of the drug, the 
surroundings must be unusually good. As a working rule a 
chronic morphine habitue must be treated at an institution. 
The method of curing these patients is described on page 716. 

Uses. — The two most important indications for the use of 
opium or morphine are pain and spasm. Acute pain, whether 
neuralgic, inflammatory, or due to distention of a canal by a 
calculus, or due to some spastic condition as an intestinal colic, 
must ordinarily be stopped by morphine or some other form of 
opium, or by one of its synthetic salts; or if the condition is 
excessively acute, inhalations of chloroform may be required. 
If the dose of morphine must be large for this purpose, it is well 
combined with atropine so that the action on the respiratory 



268 THE PRINCIPLES OF THERAPEUTICS 

center may not be quite so intense, ordinary doses of atropine 
stimulating the respiratory center. Also, sometimes peripheral 
spasm is modified by the action of the atropine. 

Conditions calling for morphine for pain are renal and hepatic 
colic, intestinal colic, lead colic, and very acute inflammatory 
or neuralgic pain. The dose for any of these colic conditions 
should be large, from J£ to }i of a grain, to be followed by a 
smaller dose in an hour, if the pain has not been relieved. Asso- 
ciated with this treatment should be a hot bath or hot fomenta- 
tions to the abdomen, to aid in the production of relaxation. 
It may be found that benzyl benzoate will be more valuable 
for these conditions without causing such narcosis as does mor- 
phine. It should be remembered that as soon as the colic ceases 
or the stone has passed, the opposition to the morphine is gone, 
and the patient may immediately become stupid, while imme- 
diately before he was alert. Therefore, such a patient should 
not be allowed to sleep, but should be kept awake until the pro- 
found effects of the morphine have passed, and if advisable he 
may be given large doses of coffee or caffeine. 

If morphine is required for such a condition as sciatic pain, 
or for neuritis, the dose need not be so large, but must be more 
or less frequently repeated; but it should be remembered that 
all other methods to ease this local pain must be tried before 
morphine is used. However, it is not justifiable to allow any 
patient to suffer, whether an adult or a child. Codeine may 
be the better drug to give, as it is less likely to cause constipa- 
tion and loss of appetite, but it is not as much of an analgesic. 

In recurrent conditions, as asthma and dysmenorrhea, mor- 
phine should be considered the last resort, as a large number of 
morphine addicts have become such through using morphine in 
asthma, and a dysmenorrhea pain is very rarely so intense as to 
require or justify morphine. A hot sitz bath, bromides, and 
alcohol in some form, or benzyl benzoate are efficient in ordinary 
pelvic pain. 

Angina pectoris is generally relieved by nitroglycerin, but 
if the heart ache persists, morphine should be given, but sharp 
cardiac pain is only temporary, if the patient lives at all, and 
chronic heart pain is better relieved by some other method. 



OPIUM 269 

Profound nausea and vomiting from any cause may require a 
hypodermic of a small dose of morphine, ordinarily }{q of a 
grain, or at most }i of a grain. Such treatment may be justi- 
fiable while other methods of treatment are being tried. 

To cause sleep in great restlessness, other drugs should 
generally be used, but if a patient is very weak, or his condition 
is serious, or he is in the midst of an acute illness, a small dose 
of morphine, perhaps by the mouth, may be all that is required, 
rarely more than }{ oi a grain. 

Occasionally an acute diarrhea is so serious as to require mor- 
phine to stop it while other more rational treatments are being 
used. A small dose of morphine, Jio of a grain, is all that is 
necessary to stop the active peristalsis; or two teaspoonfuls, 
or more, of paregoric may be the preparation of choice. The 
pain of an acute gastrointestinal disturbance often requires 
a hypodermic dose of morphine, % of a grain or more. 

If a patient who has had an hemoptysis is very nervous a 
small dose of morphine may be advisable, given hypodermat- 
ically, to quiet his nervous system, slow his heart, and relieve 
him from fear. 

For the severe pains of cerebrospinal meningitis, morphine 
at times must be given in a sufficient dose to quiet the patient. 
It is very regrettable that in locomotor ataxic pains at times 
morphine must be given, as these pains are bound to recur, and 
a morphine habit is easily established. Therefore, before re- 
sorting to morphine all physical and other medicinal methods 
should be tried. 

Occasionally, in uremic conditions, there may be sufficient 
pain, in the form of neuralgias, to necessitate an injection of a 
small dose of morphine, although it is known to act more in- 
tensely in such conditions, but if required for this purpose its 
use is justified. 

In the last stages of pulmonary tuberculosis, when there is 
great distress from air starvation, small doses of morphine are 
justifiable in preventing this terrible air hunger, even if such 
a dose must be for some little time repeated. 

In patients who are suffering from incurable cancer and who 
have pain, morphine or codeine, or perhaps benzyl benzoate, 



270 THE PRINCIPLES OF THERAPEUTICS 

should be given without hesitation. The matter of developing 
a habit is secondary ; the patient should not be allowed to suffer. 

For frequent, troublesome coughing, due to nervous irritation 
and without much expectoration, as occurs so frequently in 
acute colds and bronchitis, a small dose of codeine may be com- 
bined with ammonium chloride in a cough mixture, with great 
benefit to the patient. There is no possibility of causing a 
habit. The prescription cannot be repeated without the knowl- 
edge of the physician, and unless the patient has been a mor- 
phine habitue, he will not know that he is taking it. To 
repeat what has been said previously, there is no excuse for heroin , 
we do not need it, and it is not necessary in cough mixtures. 
Codeine answers every purpose, and the dose need not be large. 

For acute pain in the beginning of pneumonia, pleurisy, and 
pericarditis, and for acute abdominal pain in peritonitis, mor- 
phine is justifiable, and the dose should be sufficient to stop 
the pain. In peritonitis it may be necessary to repeat the drug 
for several days, provided the surgical condition that is under 
treatment, does not contraindicate it. 

Although opium and morphine will inhibit the activities of 
the glands of internal secretion, it is generally inexcusable 
treatment for such conditions. It causes more harm than it 
can possibly do good. Large doses of opium or morphine in- 
hibit the activities of the suprarenals, and also inhibit nutrition 
and normal metabolism. Therefore in glandular disturbances 
there is rarely an excuse for using these drugs. 

When there is cerebral inflammation and excitement, mor- 
phine is rarely the drug that should be used, as small doses 
tend to increase the irritability, and large doses are inadvisable. 
Therefore other brain and nerve sedatives should be used. 

DRUGS USED TO CAUSE SLEEP 
Hypnotics 

We all recognize the various conditions that prevent sleep, 
from pain to intestinal indigestion and to disturbances of the 
ductless glands, but we do not consider the causes of sleep. 
Various physiologic theories of the cause of sleep have been 
presented, and, probably, they all play some part in its produc- 



HYPNOTICS 271 

tion. The most logical theories are: (1) the fatigue prod- 
ucts; (2) anemia of the brain; (3) cerebral changes, neuron 
retraction; (4) habit. 

Perhaps the most important of all of these causes is the in- 
herited life habit of a period of sleep once in twenty-four hours. 
Also it is a fact easily demonstrated that a lowered blood- 
pressure, hence lowered cerebral pressure and anemia of the 
brain, causes drowsiness. Also fatigue products in the brain 
due to cerebral activity as well as fatigue products in the muscles 
due to muscle activity call for rest (in the brain procured only 
by sleep) to remove them and allow recuperation. Also, we 
all recognize that when we are mentally weary it is difficult to 
mentally react, to take in what is said or read, or to do the 
simplest thing well, and it is even difficult to do things correctly 
that are acts of habit and should be almost automatic. This 
condition may well be due to a retraction of the neurons, and 
may be the cause of many mistakes and accidents. 

Sleep therefore is essential, but before using drugs to cause 
sleep, all other measures should be resorted to, such as a regu- 
lated diet (stop tea and coffee), hydrotherapy, mental rest, 
fresh air, and normal exercise. However, drugs are very often 
needed, but all are more or less depressant both to the central 
nervous system and to the heart. Any one of these drugs may 
cause a habit. 

The best hypnotic from the standpoint of the ability to pro- 
duce sleep is still chloral, but it is very disagreeable to take, 
and as depression due to it is feared by many practitioners, 
other less efficient hypnotics are generally used. Bromides (the 
sodium salt the best) are always useful in sufficient doses, but 
they disturb digestion and weaken the muscular power. Scopol- 
amine is the best hypnotic for hyodermic use, and is efficient, 
except when there is an idiosyncrasy against it. This drug is 
much used in excitable insanities and in such cerebral excitation 
as delirium tremens. 

Barbital (veronal), diethylbarbituric acid, and its sodium salt 
(barbital-sodium) have replaced the synthetics sulphonal and 
trional. Barbital is as efficient as these drugs, acts more 
quickly, and the dose is very much smaller; hence there is less 



272 THE PRINCIPLES OF THERAPEUTICS 

to be excreted by the kidneys, and therefore less disturbance 
during its excretion. 

Paraldehyde acts quickly, but it is very disagreeable to take 
and therfore is not much used. 

Potassium Bromide; Sodium Bromide. — Description. — Po- 
tassium bromide occurs as white colorless crystals or granular 
powder, has a strong, saline, disagreeable taste, and is very 
soluble in water. The dose is i Gm. (15 grains). It is more 
disagreeable to take and a little more depressant to the muscular 
system than is sodium bromide. This latter salt occurs as 
colorless or white crystals or powder, is very soluble in water, 
has a salty taste, and the dose is 1 Gm. (15 grains). This dose 
is a moderate one when given three times a day for a sedative 
effect, but the ordinary hypnotic dose should be considered 
as 2 Gm. (30 grains) of either salt, given once, two or three 
hours before bedtime. As just stated, for all ordinary purposes 
sodium bromide, which has only a salty taste, is preferable 
to the potassium salt. For epilepsy the potassium salt may 
act better, as being slightly more depressant. These drugs are 
best administered in water, 1 Gm. to 5 mils, a teaspoonful. 
They should be taken largely diluted, or at least followed 
with plenty of water, else nausea is caused. 

There is no need in medicine for any other preparation of 
bromide. The much lauded strontium bromide has no advan- 
tage over the other salts, costs more, and is not needed in 
medicine. Tablets of either sodium or potassium bromide 
should not be swallowed; they should always be dissolved, else 
serious irritation of the stomach may be caused. 

Action. — Bromides are sedative to the spinal cord and to the 
brain, are depressant to the circulation, lower blood-pressure, and 
quiet and slow the heart. They slow digestion, interfere with 
the appetite, slow all metabolism, cause muscle relaxation, and 
finally muscle debility. They are partially excreted through 
the skin, increase perspiration, and may irritate the glands of 
the skin, sometimes causing papular eruptions. By their 
action in slowing metabolism, quieting brain activity, and slow- 
ing the circulation, they also lower the temperature. 

They have no external action, and, unless in concentrated 



POTASSIUM BROMIDE SODIUM BROMIDE 273 

solutions, are not very irritant to mucous membranes, but they 
may cause some nausea and vomiting if not taken well diluted. 
They are more or less rapidly absorbed, and are especially 
efficient in quieting peripheral irritation and in soothing an 
excited, irritated condition of the brain. 

Excretion begins rapidly, but when several doses have been 
taken, complete excretion is slow, and after bromides have been 
long administered, they may not be all excreted until many 
days after the last dose has been taken. Bromides are not only 
excreted by the skin and kidneys, but they are found in the 
saliva, the perspiration, and in the milk, and some may be 
excreted through the intestinal mucous membrane. 

Bromides seem to take the place of chlorides in the system, 
especially if the ingestion of chlorides is diminished. This 
reaction fixes the bromides more in the tissues, and is largely 
the reason for the length of time it takes to entirely eliminate 
them. 

Over-action. — The over-action of bromides is evidenced by a 
diminution of the reflexes, subnormal temperature, loss of 
appetite, coated tongue, dull eyes, mental apathy, increased 
perspiration often with a disagreeable odor, and loss of strength. 
There is also complete loss of sexual vitality, all sexual desire is 
lost, and impotency occurs in the male. 

Papular acne-like (sometimes pustular) eruptions on the skin 
are very frequent after even one or two doses of a bromide in 
certain patients who have this sort of idiosyncrasy. If the 
bromide is given for some time, there may occur on various parts 
of the skin peculiar, almost warty-like growths, not dissimilar 
to a tubercular syphilide. 

Patients who are actually suffering from bromism or a bro- 
mide habit have a dull expression, eyes without lustre and the 
pupils somewhat dilated; they are apathetic, have impairment 
of memory and of mentality; the heart is weak; respiration 
is slow ; there are muscular tremors, and lack of coordination in 
walking, as well as weakness of the leg muscles. The patient 
may have halucinations, and there may be actual deterioration 
of the cerebral cells. Therefore, large doses of bromide, or 
medium doses long continued, are absolutely inexcusable in 

18 



274 THE PRINCIPLES OF THERAPEUTICS 

hysterical conditions and in mental disturbances, and are fre- 
quently not needed in epilepsy. 

The treatment of the bromide habit, or bromism, is to abso- 
lutely stop the drug, to promote excretion by mild hydrothera- 
peutic measures and by mild purgatives; to give massage; to 
push nutrition; to stimulate by strychnine and by digitalis; 
and to treat the anemia. The rest cure, and later gradu- 
ated exercises and perhaps electrical stimulation to bring 
the muscles as well as the nutrition and mental health back 
to normal represent the subsequent course of treatment 
advisable. 

Toxic Action. — Acute poisoning from bromides is evidenced 
by complete prostration, stupor, dilated pupils, heart weakness, 
and respiratory failure. 

Treatment oj Poisoning. — Acute poisoning by bromides is rare, 
but if it occurs, the treatment is that of a nervous and circula- 
tory depressant poison. An emetic and a purgative should be 
given, if it is thought that any bromide is still in the alimen- 
tary canal. He should be surrounded by dry heat, with a hot 
water bag over the heart, and he should be given strong coffee 
by the mouth and strychnine and atropine injections. More 
or less frequently the bladder should be catheterized. If 
necessary, the foot of the bed should be elevated, to keep the 
blood-pressure in the cerebral centers normal. Injections of 
post-pituitary extract are advisable, and perhaps injections of 
ergot; injections of camphor are always of value. Artificial 
respiration may be needed. 

Uses. — The most important use for bromides is in spinal 
irritation and in cerebral excitement or delirium, whether due 
to some irritant, or due to inflammation of the meninges. The 
dose should be sufficient and frequent enough to quiet the 
patient. Of course it should be always remembered that 
circulatory depression will follow pushing bromide. In con- 
vulsions, whether due to irritation of the brain or spinal 
cord, in uremia, tetanus, and hydrophobia, the dose of a bromide 
must be large, and it often may be advisable to administer it 
per rectum. Stronger anti-convulsants as chloral and even 
inhalations of chloroform may be advisable. Chloral acts 



POTASSIUM BROMIDE SODIUM BROMIDE 275 

much more quickly than bromides, though the bromide action 
is more prolonged. 

Bromide is a very useful hypnotic to produce sleep in any 
nervous, irritable, or peripherally irritated individual, provided 
the circulation is good. It is of special value in hysterical 
restlessness and at times in hyperthyroidism before the patient 
has begun to improve from the rest cure. In some hysterical 
and nervous patients bromide is almost a specific, and the 
little harm that it can do when given for a short time is more 
than counter-balanced by the good that it does. 

Bromides offer a symptomatic treatment for epilepsy, but, 
when all associated possibly irritant causes have been removed, 
a bromide given in small doses daily will not only cause the con- 
vulsions to be less frequent, but may even aid in promoting a 
cure. Generally the bromide treatment of epilepsy is regret- 
table, but since its treatment with this drug is better understood 
■ — namely, that large doses should never be given, that if the 
patient's appetite fails or nutrition fails it is contraindicated, 
and that when it is administered the sodium chloride intake 
should be reduced so that a smaller dose will cause the quieting 
symptoms of bromine — it has done more good than harm. To 
repeat, it should be urged that treatment with a bromide is 
generally only symptomatic treatment, and many times not 
curative, and to cause a patient to have symptoms of bromism 
is inexcusable. 

In acute strychnine poisoning, bromides and chloral represent 
the treatment, with perhaps chloroform inhalations in the 
beginning. Whenever there is acute irritation from an over- 
dose of strychnine, bromides are curative. 

A very satisfactory use of a bromide is to prevent the cincho- 
nism of patients who must be given large doses of quinine. If 
three times as much bromide as quinine is given, cinchonism and 
disagreeable head symptoms will generally not occur, namely 
3 grains of a bromide for every grain of quinine, or i Gm. (15 
grains) of the bromide to every 0.30 Gm. (5 grains) of quinine 
is the dose advisable. When enormous doses of quinine are 
given for pernicious malarial fever, it would be inadvisable to 
give the amount of bromide called for by this rule. 



276 THE PRINCIPLES OF THERAPEUTICS 

To repeat what was said under administration, there is no 
necessity for any other bromides in medicine than the potassium 
and sodium bromide, and generally the latter is the better salt 
to use. Sodium bromide is a little less depressant than potas- 
sium bromide. Ammonium bromide is intensely disagreeable, 
and is just as depressant as the other bromides. There are 
many other preparations on the market which contain bro- 
mides or bromines, but none of them has any advantage over 
the sodium bromide. 

Chloral Hydrate (Hydrated Chloral). — Administration. — 
Chloral hydrate occurs as colorless crystals, has an acrid, bitter, 
caustic taste, and is very soluble in water. The dose is 0.50 
Gm. (7^ grains), and it is best ordered dissolved in water, 
0.50 Gm. to the teaspoonful (5 mils) as syrups do not improve 
the taste of this disagreeable drug. It is well administered in 
carbonated water, should always be well diluted, and the 
patient may eat a piece of orange or lemon after taking the 
drug. Very frequently the dose should be larger than 0.50 
Gm. 

Action. — Chloral is irritant to the skin and mucous mem- 
branes, but in solution and ointments is slightly anesthetic 
and sedative to the peripheral nerves. When it is not well 
diluted and taken on an empty stomach it frequently causes 
nausea and vomiting. It is very rapidly absorbed, and when 
given in concentrated solutions may cause stupor in a very 
few minutes. When criminally administered it has been 
termed "knock-out drops." 

It circulates in the blood as chloral, and in ordinary doses 
produces a slight diminution in the frequency and strength of 
the heartbeat, and lowers blood-pressure. The slowing of the 
heart is caused by the action on the vagus center in the medulla. 
The lowering of the blood-pressure is due to a probable depres- 
sant action on the vasomotor center and to a diminution in the 
force of the heart beat. It is also depressant to the respiratory 
center. 

The most important action of chloral is on the central nervous 
system, as it is a sedative to both the brain and spinal cord, 
and is especially sedative to the brain cells. Usually it pro- 



CHLORAL HYDRATE 277 

duces sleep in half an hour, both on account of its sedative ac- 
tion on the brain and by reducing the activity of the circulation. 
It also has a decided sedative and depressant action on the 
motor tract of the spinal cord, and is somewhat sedative to the 
motor nerves, hence the reflexes are more or less diminished, 
depending upon the amount of the drug taken. It will not 
quiet acute pain unless the dose is large enough to dangerously 
stupefy the patient. 

It slows metabolism, therefore lowers the temperature and 
impairs the appetite and digestion. 

Chloral is excreted principally by the kidneys, in part as 
chloral, but mostly in combination with glycuronic acid as uro- 
chloric (urochloralic) acid. There may be some slight elimina- 
tion through the skin and lungs. 

Over-action. —Over-action from chloral is evidenced by too pro- 
found sleep, circulatory depression, lowered temperature, and 
coldness of the extremities. 

Toxic Action.— The symptoms of toxic effect are stupor, 
generally dilated pupils, cold perspiration, weak heart action, 
and feeble pulse. The respiration generally fails, and death is 
caused by paralysis of the respiratory center. In serious 
poisoning the heart may fail at the same time as the respiratory 
center, but the patient dies in coma. 

There is a chloral habit, and chronic poisoning from chloral 
is not infrequent. The habit is generally acquired from using 
chloral for insomnia. In chronic chloral poisoning there may 
occur various mental disturbances. The patient may be at one 
time talkative, at another time morose. He may lose his mem- 
ory and be both mentally and morally abnormal. The pupils 
are likely to be dilated, the skin may show eruptions of various 
kinds, and the whole health becomes impaired. There is loss of 
appetite, all kinds of indigestion, a coated tongue, a bad breath, 
cold hands and feet, and a general lack of muscular strength, 
with more or less incoordination. With these symptoms there 
is always progressive cardiac debility. 

Treatment oj Poisoning. —In acute poisoning the stomach 
should be washed out by means of a stomach tube, provided an 
irritant emetic, as zinc sulphate 2 grams, or copper sulphate 1 



278 THE PRINCIPLES OF THERAPEUTICS 

gram, does not quickly act. It is best in this poisoning not to 
administer apomorphine, as it would add its depressant action 
on the heart to the depression already caused by the chloral. 

The patient should be kept flat, surrounded by dry heat, and in- 
jections of atropine, strychnine, camphor, and pituitary ex- 
tract should be given. Coffee may be administered by the 
mouth or rectum. It may be necessary to do artificial respira- 
tion, and massage over the heart may be of advantage. 

In chronic chloral poisoning the drug should be rapidly with- 
drawn and every means used to improve the digestion and the 
strength of the heart and circulation. The patient should be 
at rest, daily massage should be given, easily digested food 
should be pushed, laxatives if needed, and plenty of water should 
be taken to promote elimination. 

Uses. —Chloral is rarely used externally, but when it is com- 
bined with equal parts of camphor and rubbed up in a mortar, 
a thick, syrupy fluid is the result, which is sometimes used ex- 
ternally with good results over painful nerves and on parts 
suffering from pruritus. A drop or two of this solution placed 
on cotton and the cotton inserted into the cavity of an aching 
tooth will often stop the pain, but oil of cloves many times acts 
more successfully in stopping such pain. 

Chloral is the most perfect hypnotic that we possess, as it 
generally causes profound and comfortable sleep, without 
dreams, and in ordinary dosage does not affect the heart or 
cause much weakness. It should not be used when sleepless- 
ness is due to pain. It is very successful in all excited, irritated 
conditions of the brain, and in delirium, provided the heart is 
in good condition. It is not very frequently used as a hypnotic 
on account of its disagreeable taste, and on account of the fear 
of its causing cardiac depression. Probably there is too much 
fear of such depression, and chloral should be used more fre- 
quently, if a hypnotic is needed. 

It has long been used in excited mental conditions and in the 
various forms of noisy insanities, and in delirium tremens. 
When there is meningeal excitement in acute disease, as in 
pneumonia and typhoid fever, provided the heart and circula- 
tion are in good condition, chloral may be used as a hypnotic, 



PARALDEHYDE 279 

and the rest that it will give is often of great benefit to the 
patient. However, in these conditions one of the synthetic 
hypnotics is more frequently used. 

In chronic insomnia chloral, like any other hypnotic, should 
not be used frequently, lest a habit be formed. In treating 
such kind of insomnia regulation of the diet, the omission of tea, 
coffee and any other excitant, hydrotherapy and out-of-door life 
are much better methods of treatment than the administration 
of drugs. However, life- and health-giving sleep must many 
times be caused by the judicious use of hypnotics. 

In convulsive conditions, whether from cerebral irritation or 
from spinal disturbances, in uremic poisoning, in tetanus, and 
in strychnine poisoning, chloral is one of the best drugs to 
administer. The dose should not be too large. Before the 
administered chloral can act it may be well to give chloroform 
inhalations. In these conditions chloral is quite frequently 
combined with bromides. 

In conditions of high blood-pressure with nervous irritability, 
temporarily small doses of chloral may be of value, as 0.20 to 
0.25 Gm. (3 to 4 grains) given three or four times a day, after 
meals. Bromides may also be valuable in such a condition, 
but they are more likely to cause loss of appetite than the 
small doses of chloral. Of course the chloral should not be long 
given. 

In conditions of very low blood-pressure, and when the heart 
is weak, and when there is gastritis, chloral should not be used. 

Paraldehyde. — Description. — Paraldehyde is a clear liquid, 
with a pungent, disagreeable, ether-like odor, and unless very 
well diluted, causes a burning, later cooling, sensation to the 
mouth and throat. The average dose is 2 mils (30 minims), 
but it is often increased to a teaspoonful. It should always be 
administered on cracked ice and with plenty of water. 

Action. — Locally, paraldehyde is an irritant, but if well 
diluted and taken on cracked ice it will not ordinarily irritate 
the stomach. When quick action is desired, it should be given 
on an empty stomach, and, as it is very quickly absorbed, it may 
cause sleep within a few minutes. There may be at first a 
slight stimulation of the heart as from an ether, but soon there 



2So THE PRINCIPLES OP THERAPEUTICS 

is slowing of the heart and some lowering of the blood-pressure, 
but the most important action is on the central nervous system. 
It seems to act on the cerebral cells, slightly stupefying them, 
causing sleep which is generally free from restlessness and 
from dreams. On awaking, the patient generally has no un- 
pleasant symptoms. There may be a slight headache, and 
some slight weakness of the circulation and of the muscles. 
The breath smells strongly of the drug, and, as stated, the 
taste is very disagreeable, nevertheless paraldehyde should not 
be often repeated, as a paraldehyde habit can occur. 

It is excreted through the kidneys and lungs, elimination 
beginning almost immediately, but continuing for some time. 
Toxic doses cause death by paralysis of the respiration. 

Over-action. — A small dose of half a teaspoonful can rarely 
cause any symptoms other than slight faintness, if the patient 
is up. For this reason it is better that the patient be in bed 
when the dose is administered. A large dose, as a teaspoonful, 
is ordinarily not required, unless there is delirium, and gener- 
ally such a dose will cause sleep, with possibly, at first, some 
throbbing of the arteries and a slight feeling of breathlessness. 

Toxic Action. — It is probably very rare for severe poisoning 
to occur from paraldehyde, unless the dose taken is excessive. 
When death occurs after ordinary doses of paraldehyde there 
must be some other cause for the cardiac or respiratory failure. 

The paraldehyde habit does not produce any special symptoms 
of chronic poisoning. There is the desire for the drug, and 
there may be some digestive disturbances. The paraldehyde 
habit is not frequent. 

Treatment of Poisoning. — The treatment of an overdose of 
paraldehyde would be to evacuate the stomach, if it was thought 
that it had not all been absorbed ; to administer hypodermatically 
atropine and strychnine; to keep the patient warm; and to do 
artificial respiration, if needed. Coffee may be administered 
by the mouth. 

Uses. — The only use for paraldehyde is as a hypnotic and to 
quiet cerebral excitement. Simply to produce sleep it is not 
now often used, other drugs have taken its place. It is dis- 
agreeable, and many patients have for a few minutes a very 



TRIONAL SULPHONAL 28 1 

unpleasant faintness before sleep is produced. It is, however, 
a very useful, and, ordinarily, a harmless hypnotic. 

It has been largely used in delirium tremens; it primarily 
satisfies the craving for a stimulant, and secondarily produces 
sleep. In convulsive conditions it, perhaps, is not used as often 
as it should be, as its action is rapid, and even in good sized 
doses is as safe a drug as large doses of chloral. 

Thonal(Sulphonethylmethane) — SvAj>honal(Sulphonmethane) — 
Description. — Trional and sulphonal both occur as colorless, 
odorless crystals, the trional having a mildly bitter taste, the 
sulphonal almost tasteless, both practically insoluble in water, 
and the dose of each is 0.75 Gm. (12 grains). Both should be 
ordered in powder, and best administered in hot milk or hot 
malted milk, the trional from one to two hours before sleep is 
desired, and the sulphonal, which acts more slowly, four or five 
hours before bedtime. These doses are small, and frequently 
much larger doses should be given. 

Action. — Trional is absorbed slowly, but less slowly than the 
sulphonal. The principal action of these drugs is on the cere- 
brum, producing a quiet sleep. They seem to have no special 
action on the heart, except that during the five to eight hours of 
sleep which they cause the blood-pressure is lowered and the 
pulse is less rapid. 

There is very little after effect from these drugs, except 
possibly some lassitude, and in the latter part of the following 
day, especially if the drug has been taken on two successive 
nights, there is a desire to sleep. Neither of these drugs will 
quiet pain. 

The drugs are eliminated through the kidneys, and, if large 
doses are taken or if the drugs are continued too long, they may 
irritate the kidneys and cause a destruction of the hemoglobin 
of the blood and the appearance of hematoporphyrin in the urine. 
Therefore, if for any reason either trional or sulphonal is taken 
for any length of time the urine should be carefully watched. 
The appearance of hematoporphyrin in the urine shows that 
the drug should be immediately stopped. 

Over-action. — There are no symptoms of the over-action of 
either trional or sulphonal except that of too prolonged sleep, 



282 THE PRINCIPLES OF THERAPEUTICS 

loss of appetite, lassitude, muscular weakness, mental apathy, 
and, as just stated, the appearance of hematoporphyrin in the 
urine. Albumin may appear in the urine before hematoporphy- 
rin is found. Acute poisoning is probably rare, as an excessive 
dose must be taken and absorbed to cause such a condition. 

Treatment oj Poisoning. — The treatment of poisoning is to 
cause rapid evacuation of the bowels, to cause perspiration to 
relieve the kidney irritation, to give large amounts of water, and 
if there is cardiac depression to give stimulation, it being re- 
membered that to every hypnotic depressant caffeine, atropine, 
and strychnine are antidotes. 

In chronic poisoning and in the sulphonal or trional habit, 
besides stopping the drug, large amounts of alkalies should be 
given, and the food should be largely carbohydrate. 

Uses. — Trional and sulphonal are used only to produce sleep. 
They have been supplanted by barbital (veronal) principally 
because it acts more rapidly, the dose is much smaller, and, 
therefore, the irritation of the kidneys, which may occur from 
these synthetic drugs, is less. 

Barbital {Diethylbarbituric Acid) {Veronal). — Description. — 
Barbital is another synthetic hypnotic which occurs as a white 
crystalline powder, is slightly bitter, and is rather insoluble in 
water. The dose is 0.30 to 0.50 Gm. (5 to 7^ grains). If 
administered in tablets, they should be crushed before swallow- 
ing. It is best ordered in powder, given with hot milk or malted 
milk, one-half to one hour before bedtime. 
• Barbital-sodium (veronal-sodium) also occurs as a white 
crystalline powder, has a bitter taste, and is very soluble in 
water. The dose of this preparation is the same as that of 
barbital, and it should be administered in the same way. 

Action. — Barbital and its sodium salt, which is generally the 
best preparation to use, is rapidly absorbed and acts principally 
on the central nervous system. It quiets nervousness and pro- 
duces sleep, but has only a slight analgesic action and cannot 
stop acute pain. It may cause slowing of the pulse and lower- 
ing of blood-pressure similar to all synthetic hypnotics, but it 
rarely causes, in ordinary doses, any unpleasant symptoms. 
During its action the temperature sometimes is lowered and 



SCOPOLAMINE HYDROBROMIDE 283 

when the patient awakens he may have a slight headache and 
some feeling of lassitude and muscle relaxation. 

Over-action. — The only over-action is slight cardiac depression 
and too prolonged sleep. Acute poisoning rarely occurs, and 
should be treated similarly to poisoning from sulphonal or trional. 
It should be emphasized that when any of these drugs cause 
poisoning, the patient should be given large amounts of water 
and alkalies, as sodium bicarbonate and sodium citrate. 

Occasionally a patient is found who has the veronal habit. 
It should be rapidly stopped; temporary need for a sedative 
may be overcome by the administration of bromides for a short 
time, and then weaning the patient from all sedatives. The 
rest of the treatment is nourishing food and stimulation. 

Uses. — Barbital-sodium represents at the present time the best 
synthetic hypnotic, and the dose should be sufficient, depending 
upon the individual. It may vary from 0.20 to 0.50 Gm. (3 
to 7JH2 grains). Doses on subsequent nights may be smaller, 
provided the original doses were large. It should be given 
with plenty of water. As with all hypnotic drugs, the phy- 
sician should not be content until the drug has been stopped 
and the patient is made to sleep by physical methods and by 
correcting mistakes in the diet and hygiene. 

Luminal, N.N.R. (phenobarbital, phenyl-ethyl-barbituric 
acid), is a white powder, has a slightly bitter taste, and is in- 
soluble in water. It is a useful hypnotic in simple insomnia, 
and like all synthetic hypnotics it may cause some morning 
depression. It has been used in epilepsy, best given at bed- 
time. The dose is 0.10 to 0.20 Gm. (i^ to 3 grains). 

Luminals odium, N.N.R. (phenobarbital-sodium) occurs as 
a white powder, which is very soluble in water. The dose is 
practically the same as that of luminal. 

Scopolamine Hydrobromide (Hyoscine Hydrobromide). — ■ 
Description. — Scopolamine hydrobromide occurs as colorless 
crystals, is very soluble in water, and the dose is 0.0003 Gm. 
(Hoo grain), best administered hypodermatically. 

Action. — Scopolamine hydrobromide is an atropine, and in 
patients who have idiosyncrasy against atropine it may cause 
considerable cerebral excitement and delirium. Ordinarily, 



2S4 THE PRINCIPLES OF THERAPEUTICS 

however, its action is principally on the central nervous system; 
it rapidly produces sleep. With this sleep there may be con- 
siderable cardiac depression. The drug will not stop pain, 
but without pain it is generally a useful hypnotic in conditions 
requiring the administration of such a drug hypodermatically. 

Over-action. — Over-action is that of excitement in those who 
have an idiosyncrasy against an atropine, and large doses may 
cause cardiac depression. The treatment of such conditions 
would be to combat the symptoms present by the usual methods. 

Toxic action would require the usual stimulation treatments, 
and frequently there may be, when sleep has been produced by 
the hypodermatic administration of this drug, the necessity 
for administering cardiac and vasomotor simulants. 

Uses. — The principal use of this drug is as a hypnotic in deliri- 
um, in the excitement of insanity, occasionally in delirium 
tremens, and when the stomach will not tolerate other hypno- 
tics. The beginning dose is J^oo of a grain, but some patients 
require Koo °f a g ram > and even larger doses are administered 
at times. 

The drug has been used in such conditions as paralysis agitans 
with more or less success. When the drug is frequently given 
a tolerance to ordinary dosage generally occurs. 

DRUGS USED TO CAUSE GENERAL ANESTHESIA 

Sir Humphrey Davy, about the year 1800, suggested that 
nitrous oxide gas be used to stop pain in surgical operations, and 
Horace Wells, of Connecticut, in 1844, showed its use as an 
anesthetic in dentistry. William Morton, an assistant of 
Wells, and Jackson, a chemist, demonstrated ether narcosis 
in the Massachusetts General Hospital in 1846, but C. W. Long, 
of Georgia, had used ether as an anesthetic in 1842. By the 
year 1847 ether was used as an anesthetic throughout the 
civilized world. 

Chloroform was discovered in 1831, but was first used for 
anesthetic purposes in 1847 D y J- Y. Simpson, of Edinburgh. 
For many years chloroform was the most used anesthetic in 
Europe, even up to thirty years ago. 

In spite of many new drugs and combinations of drugs the 



GENERAL ANESTHESIA 285 

substances used for general anesthesia are still ether, chloro- 
form, nitrous oxide gas, and a combination of oxygen and ni- 
trous oxide. The safest of these for major surgery is ether. The 
safest for very minor surgery, as extraction of teeth, is nitrous 
oxide gas and especially the oxygen-nitrous oxide combination. 
For short periods of relaxation, or for dulling of the sensibility 
to prevent pain, and in certain convulsive conditions, chloro- 
form is the anesthetic of choice, but rarely should chloroform 
be used for general anesthesia. The combination of oxygen 
and nitrous oxide as an anesthetic a few years ago had its 
strong advocates all over this country, and was largely used 
in many of our best hospitals. At the present time ether has 
again largely supplanted this oxygen-nitrous oxide combination 
but a few surgeons still believe that it is a safe, useful anes- 
thetic. Some surgeons go so far as to state that it is a very 
dangerous anesthetic to rely upon in long operations. Cer- 
tainly it should never be administered except by an expert, and 
an expert for this kind of an anesthetic can only be found 
associated with a large, first class hospital. 

It should be urged at the start, in a discussion of this subject, 
that anesthesia is a special branch of medicine, and that a 
skilled anesthetist, except possibly in emergencies, should be 
the only one to administer the anesthetic. The life of the 
patient is in his hands. For that reason he should be a con- 
sultant in the case. He should know the condition of the 
patient, the surgical operation to be done, the strength of the 
heart, the blood-pressure, the sufficiency of the kidneys, and 
any other detail that belongs to the history of the patient whom 
he is to anesthetize. He then assumes a large part of the 
responsibility for the life or death of the patient; and it is unfair 
for any surgeon to expect this responsibility when the anesthe- 
tist does not have this knowledge. 

More frequently than statistics show does death occur during 
anesthesia, and the cause of these deaths cannot be better out- 
lined than by a paper presented at a meeting of the American 
Association of Anesthetists, held at Chicago, in June, 1918, 
by Dr. E. M. Sanders 1 . Sanders thinks that there is one 

1 American Journal of Surgery, April, 1919, p. 43 



2S6 THE PRINCIPLES OF THERAPEUTICS 

death from anesthesia for every one thousand administrations, 
this death being due to "the anesthetic, to the surgeon, and 
to the hazardous risk." Death "due to anesthesia" will 
occasionally occur, because honest surgeons and anesthetists 
assume the risk of a hazardous case, one which has a chance to 
live if the operation is done, and such a death is excusable. 
Inexcusable deaths are those due to inexperienced and untrained 
anesthetists, to anesthetists who do not minute by minute 
attend to their part of the operation, and to surgeons who 
unnecessarily prolong the operation, unnecessarily expose the 
patient to loss of heat, allow unnecessary bleeding, unneces- 
sarily manipulate organs and nerve plexuses in the abdomen 
which should be handled with greater care, and unnecessarily 
prolong a position of a patient in which it is difficult for him 
to breathe or to have his heart properly beat. 

Sanders lists the causes of deaths on the operating table 
or soon afterwards as "shock; hemorrhage, primary or second- 
ary; overdose of the anesthetic paralyzing the higher centers; 
underdose of the anesthetic allowing fibrillation or paralysis 
of the heart; acute dilatation of the heart; acapnia; post- 
operative pneumonia; and acidosis." Occasionally, of course, 
as he notes, an embolus or cerebral hemorrhage may occur, or 
death may occur from thymus pressure or on account of 
thyroid intoxication. 

As he urges, there can be no question of the necessity of a 
careful reading of the systolic, diastolic, and pulse pressure of 
a patient to be operated, and also the advisability of some test 
of cardiac muscle strength. This knowledge is well gotten first 
hand by the anesthetist. 

The danger of partial anesthesia, which is greater with 
chloroform and with oxygen and nitrous oxide gas, should be 
recognized, and the decision that a patient is not sufficiently 
anesthetized, although he is apparently ready for operation, 
should be made by an expert. Also to carelessly allow a patient 
to partially come out of the anesthetic and then to hustle him 
back into profound anesthesia is many times the cause of an 
over-dose of the anesthetic. 

It has long been urged by a few, but carelessly omitted by 



GENERAL ANESTHESIA 287 

many, to thoroughly cleanse with antiseptics the mouth and 
throat before operation. Also, if the operation is not one of 
emergency, all infected teeth and infected tonsils should be 
removed before a major operation is done. Many a post- 
operative pneumonia or other serious infection occurs because 
the patient is a carrier of pneumococci or of streptococci, often 
the viridans or the hemolyticus, or both. Also, a preventive 
of suction pneumonia is to keep the throat and mouth as clean 
as possible during the anesthesia. 

Sanders urges a recognition of the psychic condition of the 
patient, and of the necessity of overcoming the terrible fear 
which some patients have of operation. It has also been urged 
by Crile that this condition of the patient about to be operated 
upon be noted. There is no question that fear disturbes the 
endocrine glands, injures the tone of the circulation, and causes 
an increased thyroid secretion, hence a larger amount of 
the anesthetic is needed. Therefore, the quiet assurance of 
the surgeon, and especially the quiet, calm influence of the 
anesthetist is very important for these patients. In these 
instances it may be well to give a preliminary hypodermic of 
morphine with atropine. It is in these cases that Gwathmey, 
of New York, who has studied the subject of anesthesia so 
carefully and written many articles on the value of the different 
anesthetics, urges the use of rectal anesthesia, the patient 
being given the anesthetic without his knowledge, thinking it 
is simply an enema. 

Crile coined the word or phrase "anoci-association" as de- 
scriptive of his method of conducting anesthesia. The object 
of this anesthesia is to block the nerve or nerves of the parts to 
be operated so that reflex influences cannot reach the brain and 
cord. Therefore not only pain cannot be felt, but also shock 
cannot occur. The whole procedure is to dull the patient's gen- 
eral sensibilities with morphine and scopolamine as a prelimi- 
nary injection, then give a general anesthetic in small amount 
(Crile often prefers nitrous oxide) and as soon as the patient is 
anesthetized, to inject the local anesthetic procaine (novocaine) 
1 part to 4,000, into the nerve trunks of the part to be operated. 
At the close of the operation, into the cut sensitive tissues is 



28S THE PRINCIPLES OF THERAPEUTICS 

injected quinine and urea hydrochloride. This local anesthetic 
is used for the purpose of preventing post-operative pains. 

It will be seen that this whole treatment represents a great 
deal of anesthesia, and it would seem that so much would 
rarely be needed. 

General anesthesia is always a serious proposition, and both 
ether and chloroform may injure the kidneys, the heart, and the 
liver. Therefore, frequent administration of an anesthetic is 
rarely excusable, and is regrettable when it must be repeated 
within a short time. On the other hand, it is rarely advisable, 
under one general anesthesia, to do minor operations, such as 
tonsillectomies, dental operations, etc., before or after a major 
operation. 

Both ether and chloroform cause progressive paralysis of the 
brain and cord, the highest centers being first affected, and 
finally the fundamental centers in the medulla. The reflex 
centers of the pelvic region, of the rectum, and of the genitalia 
are often the last to be paralzyed in ordinary anesthesia ; there- 
fore the anesthesia, if general, must be profound before opera- 
tions in these regions can be performed. However, generally, in 
most patients sensation is lost last in the part to be operated 
upon, probably because the patient's mind is fixed on that region 
before the anesthetic is administered. 

It must be conceded that chloroform is the most dangerous 
anesthetic, and Gwathmey, after studying the statistics, states 
that deaths under chloroform by the usual drop method occur- 
red in from one in a thousand to one in three thousand cases, 
while deaths on the operating table from ether, by the drop 
method, occurred only in from one to five thousand to one in 
ten thousand cases. Gwathmey believes that the vapor method 
of administration of ether with definite quantities of air and 
oxygen is safer than the open drop method. 

Crile 1 states that after prolonged anesthesia under ether 
the brain, suprarenals and liver show marked histologic changes, 
while after the same length of time under nitrous oxide anes- 
thesia there are no apparent changes in these organs. However, 
the alkalinity of the blood was more diminished, and general 
1 The Journal A. M. A., Dec. 16, 1916, p. 1830. 



GENERAL ANESTHESIA 289 

acidity more increased under nitrous oxide than under ether, 
although the more intense the anesthesia in either case the 
greater the acidosis produced. It seems demonstrated that the 
reserve alkalinity of the blood is greatly reduced during pro- 
found anesthesia, and acidity may play a part in the anesthetic 
action of the anesthetic drugs during anesthesia, and the greater 
the acidosis the more profound the anesthesia. Patients who 
have suffered severe injury, or prolonged pain, or have been 
starved, or have been subjected to serious exertion or to serious 
infection, have a mild acidosis, or at least are on the verge of 
that condition, and Crile thinks this is the reason that the anes- 
thetic acts more seriously and may be dangerous in these cases. 
Also, any patient who has had a long preceding vomiting period, 
as the nausea of pregnancy, or has had serious diarrhea and in- 
sufficient food, makes a bad risk for general anesthesia. Crile 
thinks that in such cases nitrous oxide (which he finds safe if 
properly administered) should be the anesthetic of choice, unless 
local anesthesia can be used. 

All this only emphasizes the fact that the anesthetic must 
be chosen to fit the patient. Nitrous oxide — oxygen certainly 
has a field as an anesthetic in minor surgery, i.e., very short 
operations, and may be of advantage when there is a lung con- 
dition that would make the use of ether dangerous, or a kidney 
inflammation, acute or chronic, that would make either ether 
or chloroform inexcusable. The administration of nitrous 
oxide in any form is inexcusable with high blood-pressure, and 
the administration of chloroform is certainly inexcusable in 
conditions of shock or very low blood-pressure, or when there 
is myocardial weakness. 

While the majority of teeth extractions are perhaps done 
under nitrous oxide, and perhaps more should be done under 
nitrous oxide — oxygen, still, prolonged operations on the jaws 
are now much better done under ether anesthesia. 

Alcoholic and hysterical patients are perhaps best anesthetized 
with nitrous oxide — oxygen, as they generally take ether badly. 
Especially in teeth and throat operations care should be taken 
that the saliva and blood do not trickle down into the throat to be 
swallowed and cause nausea, or to be sucked into the trachea 

19 



29O THE PRINCIPLES OF THERAPEUTICS 

and cause coughing and perhaps insufflation infection. The 
back part of the mouth may be packed with gauze to prevent 
insufflation and swallowing of blood and the broken teeth or 
fillings that may drop into the mouth during large extractions. 
Again it is seen that the ^administration of the anesthetic and 
the care of the patient during the anesthesia requires an expert. 

There is a great deal of discussion as to whether local anes- 
thesia or general anesthesia is the better in tonsillectomy, which 
operation is being more and more frequently done, and although 
doubtless many tonsils are removed unnecessarily, very many 
times treatment other than radical enucleation is not justi- 
fiable. Diseased tonsils must be removed, as apparently deep 
pockets of infection can rarely be successfully eradicated in any 
other manner. Also more and more frequently must tonsils be 
removed in the adult, and even after middle life. Consequent- 
ly, the subject of the proper anesthetic is a live one. A very 
able paper on the advantages of general anesthesia in tonsillec- 
tomy is presented by Becker 1 and is followed by a discussion by 
several who believe that local anesthesia is better in these 
cases. 

Gwathmey believes that rectal anesthesia is of great value 
when operations must be done on the mouth, throat, or face and 
the anesthetic cannot be well administered during the operation. 
The principal reason that rectal anesthesia has not become more 
popular is because the amount of the drug absorbed cannot be 
determined, and it may be difficult to remove it entirely from 
the colon when signs of over-action of the anesthetic occur. 
While washing out the lower intestine theoretically should 
immediately remove the unabsorbed anesthetic mixture, still it 
would be difficult to determine how much reverse peristalsis 
might have occurred. 

Mann 2 found that there is a leucocytosis during ether anes- 
thesia if the anesthetic is given for some time, due he thinks 
to action on the bone marrow. He found the red blood cor- 
puscles and their hemoglobin content were not changed by 
ether anesthesia. 

1 Penn. Med. Journ., Feb., 1920, p.273. 

2 The Journal A. M. A., July 15, 1916 p., 172. 



GENERAL ANESTHESIA 29 1 

Rectal Anesthesia. — Rectal anesthesia, so thoroughly develop- 
ed by Gwathmey, has been very well described by Johnson. 1 
He states that at that date Gwathmey had performed 2,000 
operations under rectal anesthesia with no fatalities. 

In nervous, irritated, and fearful patients the mixture may 
be administered as an enema, and not knowing its character 
the patient quickly drops off into sleep without alarm or fear. 
Patients are prepared for this rectal anesthesia the same as for 
any other anesthesia, except that the rectum must be as clean as 
possible in order to absorb the anesthetic. The method advised 
is to administer a dose of castor oil at 2 P. M. on the day before 
the operation. As soon as the oil has acted that evening, a 
colon irrigation is given until the water comes away clear. On 
the morning of the operation, one or two colon irrigations are 
again given, and two hours before the operation 5 to 15 grains of 
chloretone are given by the mouth. Thirty minutes before the 
regular anesthesia, the patient is given subcutaneously from }/q 
to J4 grain of morphine and 3^50 grain of atropine, and immed- 
iately thereafter is given by rectum the following: 

Paraldehyde 10 mils 

Olive oil • 60 mils 

Ether ioo mils 

The patient is kept quiet in a darkened room until he is surgi- 
cally unconscious, which will require, says Johnson, from 15 to 
30 minutes. The odor of ether appears on the patient 's breath 
in about four minutes after the injection. Johnson finds the 
absorption is slow and uniform, the patient absorbing about two 
ounces an hour. The doses of the drugs are of course deter- 
mined "by the age, weight, and habits of the patient, about 1 
ounce (30 mils) of ether being required for every twenty-five to 
thirty pounds of body weight. " He says when the paraldehyde 
is used this may be lessened, but that they " never give over 6 
ounces of a 75 per cent, oil-ether mixture to adults, regardless of 
weight. Children require only from 50 to 60 per cent, of ether, 
and when under nine years of age, no preliminary treatment. " 
In this rectal anesthesia stertorous breathing and loss of 

1 New York Medical Journal, Oct. 28, 1916, p. 846. 



292 THE PRINCIPLES OF THERAPEUTICS 

ocular reflexes should not occur, as they are danger signals. 
If they do occur, from 1 to 2 ounces or all of the mixture 
should be withdrawn from the bowel, and the bowel be mas- 
saged in the direction of the colon outflow, to promote entire 
evacuation of the ether; the bowel may also be irrigated with 
cold water. If the patient seems to be coming out of the 
anesthesia, the mouth and nose should be covered, when they 
quickly go back into smooth, easy surgical narcosis. The 
tongue should be kept forward and the jaw projected, with the 
head extended as is usual in all anesthesias. After the opera- 
tion, the colon is irrigated. 

This method of anesthesia as suggested may be useful 
especially in operations on the head, neck, throat, or chest, and 
for patients who are likely to have bronchial irritation and 
profuse bronchorrhea from the ether inhalations. Contra- 
indications are diseases of the intestines, operations on the 
pelvis, and, in general, laparotomies, on account of gaseous 
distention caused. 

It would seem that rectal anesthesia should be the method 
of choice only in exceptional instances, but in certain con- 
ditions it is doubtless of value. However,. with the uncertainty 
of the amount of ether absorption it would seem more unwise 
to administer morphine before the anesthesia than it is in the 
ordinary inhalation method, also the paraldehyde complication 
would tend to befog the signs of the degree of narcosis. 

Pre-operative Care of the Patient. —As previously urged, 
except in operations of emergency, the skilled anesthetist 
should partake in the diagnosis and clinical examination of 
the patient to be operated upon, i.e., both he and the surgeon 
should share the responsibility of the patient coming through 
the operation safely. 

1. Of primary importance is the condition of the circulation, 
namely, the presence or absence of heart lesions; the blood- 
pressure, systolic and diastolic; the condition of the arteries; 
the estimated strength of the myocardium, as shown by the 
systolic, diastolic, and pulse pressure, and by simple tests of its 
strength (rapidity of pulse, etc., in different positions). 

A high systolic pressure, and especially a high diastolic 



GENERAL ANESTHESIA 293 

pressure, or hardened arteries, should preclude, ordinarily, the 
use of nitrous oxide gas or nitrous oxide — oxygen gas as anes- 
thetics. For short operations in such a condition chloroform is 
probably the safest anesthetic to use, as there is always a fall 
of blood-pressure under chloroform. If the blood-pressure is 
low and the heart weak, and there are valvular lesions which 
may presume more or less cardiac degeneration, chloroform 
should not be used as the anesthetic. For a short operation the 
nitrous oxide — oxygen may be used, but ether is generally the 
safest anesthetic. 

2. When possible, a twenty-four hour specimen of urine 
should be carefully examined, and if chronic kidney disturbance 
is found, prolonged administration of either ether or chloroform 
is not advisable (though chloroform, if the blood-pressure is 
high, is perhaps safer than ether) , and the nitrous oxide-oxygen 
anesthetic is the one of choice. If an operation must be done 
and there is evidence of considerable chronic nephritis, the 
ability of the kidneys to excrete had better be tested by the 
phenolphthalein test. If the kidneys are very insufficient and 
the operation must be done, some form of local anesthesia, or 
spinal anesthesia, is generally the safest. 

3. If there is bronchitis, or asthma, or some other more 
serious lung condition present, ether inhalations should, if 
possible, be avoided, and the safest method of administration, 
unless otherwise contraindicated, would seem to be rectal 
anesthesia. If the operation is a short one, chloroform inhala- 
tions may be given. 

4. The condition of the thyroid should be noted. Hyper- 
thyroidism or a large thyroid tumor should cause the greatest of 
care by the anesthetist and may preclude all major operations. 
In hyperthyroidism generally the patients are best prepared for 
anesthesia by previous injections of morphine and atropine. 
It is possible that rectal anesthesia is advisable in these cases. 
However, unless an operation is absolutely necessary in a case 
of toxic hyperthyroidism such operations should not be done in 
that condition until the hyperthyroidism has been previously 
controlled by medical methods, if possible. 

5. There is not enough data to determine how frequently 



294 TH E PRINCIPLES OF THERAPEUTICS 

enlarged thymus glands are the cause of sudden deaths during 
anesthesia. The thymus gland is found not infrequently 
enlarged in adults, and it may be one cause of death on the 
operating table. The upper sternal region should be carefully 
percussed, and if there is any doubt in the mind of the surgeon 
or anesthetist as to an enlargement of this gland, x-ray pictures 
should be taken. A few x-ray treatments of the gland, if it is 
found enlarged, may remove the danger of its causing sudden 
death during an anesthesia. 

6. Very important and not to be neglected, provided the 
operation is not one of emergency, is to remove infected tonsils 
and infected teeth, and to treat pyorrhea. Not only may the 
germs from these infections be causing symptoms, but they are 
more likely to cause serious symptoms after an anesthetic and 
an operation. Many a death from pneumonia or from septic 
infection or from streptococcus hemolyticus after operation has 
been due to an infected mouth. To repeat, unless an operation 
is one of emergency, it is inexcusable to-day to give any inhala- 
tion anesthetic when the mouth is seriously infected. Also 
the post-operative risk is greatly intensified with such foci of 
infection. 

Preparation of the Patient for Operation. — i. In the first 
place, when the operation is not one of emergency the patient 
should receive for two or three days before the operation an extra 
amount of carbohydrate food with a minimum amount of fat 
and a small amount of protein. This diet will prevent the fre- 
quent acidosis which so often occurs after operations on account 
of the prolonged inability to take starchy foods. 

2. While masses of fecal matters should not be in the bowels, 
and the bowels should be as clean as possible before the opera- 
tion, still the laxatives needed are best given two days before 
the operation, not on the day before or on the morning of the 
operation. In the first place, most cathartics tend to cause 
an increased amount of intestinal gas, to the disadvantage of the 
surgeon in abdominal operations and to the disadvantage of the 
patient after the operation, because paralysis of the bowels may 
occur from the distention, because the diaphragm is interfered 
with in its respiratory work, and because the heart may be 



GENERAL ANESTHESIA 295 

pressed upon. In other words, anything that tends to produce 
tympanites or paralysis of the bowels after operation is vicious 
and is inexcusable treatment. If it occurs, the surgeon should 
have the comfortable feeling that he did not cause it. Also 
profuse catharsis just before an operation is vicious because of 
the circulatory prostration that it causes. No well individual 
can have several watery movements of the bowels without feel- 
ing the circulatory depression that accompanies and follows it. 
Such prostration is certainly not desirable in a patient who is to 
be subjected to an anesthetic, to the cutting of nerves, to per- 
haps unavoidable blood loss, and to the removal of more or less 
important organs. Also such loss of fluid adds its quota to the 
production of surgical shock. 

Although a cathartic should not be given on the night before 
the operation, it may be well to give a small enema two or three 
hours before the operation in the morning, to clean the lower 
part of the intestine. 

3. It is a mistake to too long starve a patient before the 
operation; and the best time for an operation, if it is not one 
of emergency, is in the early morning hours. The patient is 
fresh, and has not had to wait all day expectantly for the oper- 
ation. Also, the surgeon is fresh, and is better prepared men- 
tally and physically to operate. However, starvation from a 
small supper at six o'clock of the night before and nothing in the 
stomach the next morning before the operation, and then the 
patient too ill with the post-anesthesia disturbed stomach to 
take nourishment until perhaps the evening of the day of the 
operation, is a mistake. There is no reason why a patient, two 
or three hours before the operation, should not have some simple 
nourishment, such as a cup of hot bouillon or a cup of black 
coffee, preferably with sugar. If the patient vomits during the 
anesthesia, there is nothing to come up of any harm, even. if he 
has retained it in his stomach, which he ordinarily would not do. 
In the case of a young child who does not know that he is to be 
operated upon and therefore has no fear, a small cup of malted 
milk may be given three or four hours before the operation. 

4. False teeth should be removed; the nose sprayed; and the 
mouth and throat cleansed with some mild antiseptic solution, 



296 THE PRINCIPLES OF THERAPEUTICS 

best boric acid, before the anesthetic is begun. The patient 
should then pass urine. In women, hairpins should be removed, 
and a firm fitting cap put around the head, but not an air-tight 
cap to cause perspiration. If the anesthetic is to be ether or 
chloroform, the face should be anointed with vaseline or 
cold cream. The anesthetist should notice the character 
of the pulse and its rapidity, and the patient is ready for the 
anesthetic. 

Caxe of The Patient In The Operating Room. — During the 
anesthesia the patient should be placed in as comfortable a 
position as is possible, and the operating table should not be too 
narrow and should not be too short. It is rarely excusable to 
tie a patient 's arms across his chest. This dead weight during 
the profound anesthesia is a great impairment to proper res- 
piration, and the position is ordinarily inexcusable. If his 
arms cannot be down at his sides on the table, they may be 
gently fastened upwards and backwards, not far enough to 
strain the axillae ; neither should they be allowed to hang off the 
table or in an awkward position, lest injury to some nerve or 
to the circulation occur and paralysis follow. The anesthetist 
may care to watch the radial pulse as well as the temporal or 
facial pulse. The radial pulse is an earlier indication of cardiac 
failure than are the other two pulses. 

In the next place, every move and turn given the patient 
should be as gentle as though he were awake. There can be no 
excuse for operating room roughness. 

Generally it is best for a patient to be anesthetized in a room 
adjacent to the operating room, or perhaps even in his or her 
own bed, and then be placed on a carriage and gently rolled to 
the operating room. 

Many times it may be best to administer morphine and atro- 
pine a half hour or more before the anesthetic is begun, but as 
routine it is not advisable. Morphine interferes with the res- 
piration, and atropine interferes with the normal reaction of 
the pupil. Consequently, the indications relied upon for over- 
action of ether and chloroform are more or less interfered with 
when these drugs have been previously given. However, such 
administration does prevent severe nervousness and dread of 



GENERAL ANESTHESIA 297 

the anesthetic, and also may allow less of the anesthetic to be 
used. On the other hand, it is not as easy to decide that the 
patient is sufficiently anesthetized for the operation to begin, 
and many times serious nerve shock is caused by such insuffi- 
cient anesthesia. 

It is unwise for much talking to be done in the operating 
room. Speed with effectiveness should be the rule. Speed 
with carelessness is inexcusable. The skilled anesthetist should 
be the commander, to decide when the operation should begin, 
to decide when, in certain conditions it is necessary to stop the 
operation, and to decide when it is necessary to change an abnor- 
mal position of the patient — namely, one that interferes with res- 
piration or with normal cerebral blood-pressure. In plethoric 
patients a high Trendelenburg position should not be allowed, 
at least for any length of time; also not in high blood-pressure. 
On the other hand, a prolonged Trendelenburg position should 
not be rapidly dropped; the table should be lowered gradually 
to accustom the anesthetized patient to this sudden loss of cere- 
bral pressure. Also in lithotomy positions or for pelvic oper- 
ations the heavy legs should not be allowed to hang too long in 
harness or to fall too far over, to strain the sacro-iliac joints. 
Many a sacral disability has begun on the operating table. 

During the operation the patient is rarely allowed to lose 
bodily heat, but after the operation is finished, during the 
cleaning and the bandaging, many a patient is allowed to be- 
come seriously chilled. Care should be taken that this does not 
occur. If it is necessary for a patient to be raised to properly 
bandage, he should never be held upright for even a moment, or 
even partially upright, or even rolled on his side, especially the 
left side, while he is profoundly anesthetized, nor for hours after 
he comes out of the anesthetic. 

The skilled anesthetist knows how to care for the tongue ; that 
the epiglottis does not fall over the glottis; how to care for the 
saliva or perhaps regurgitated gaseous fluid from the stomach, 
so that it is not sucked into the larynx. A suction apparatus 
(often best combined with an anesthetic vaporizer) should be 
used, especially in mouth and throat operations. The anes- 
thetist decides when to push the anesthetic and when to slow it, 



298 THE PRINCIPLES OF THERAPEUTICS 

and when the heart needs stimulation by some hypodermic treat- 
ment, or when more strenuous treatments are necessary, such 
as artificial respiration or raising the feet and legs or perhaps 
the body. Hiccough in profound anesthesia is a bad symp- 
tom, calling for a careful study of the patient. These things 
cannot be taught by book; they must be learned as any other 
specialty is learned, from a skilled specialist. 

Care of the Patient After Operation.— The patient should be 
returned to a warm bed; but hot water bags should not be put 
on his bare skin, or used hot enough to cause blisters. The 
still insensible patient cannot tell how hot the application is. 
He should He fiat, without pillows, the head best turned to the 
side, the nurse watching the pulse, and removing with swabs or 
soft towels the strings of mucus from his mouth. Whether it 
is advisable, as he is coming out of the anesthetic (provided he 
has not had morphine and atropine or scopolamine before the 
anesthetic was given) to give him an injection of \^ or }^ of a 
grain of morphine to prevent post-operative pain, must be 
decided by the anesthetist and the surgeon. Sometimes it is 
good judgment; many times it is not needed, and especially not 
as often since less cathartics and less starvation occurs before 
the operation. Also, if carbohydrates have been pushed several 
days before the operation, there is less vomiting, and the 
patient can take nourishment sooner, and acidosis is not as 
likely to occur. Especially inadvisable is a morphine injection, 
unless it is positively needed, if the patient is known to be 
prostrated or nauseated when he comes out of the quieting 
effect of the morphine. 

If considerable anesthetic has been given, and the operation 
was a long one and the patient has perspired freely, or if much 
blood has been lost, it is advisable, before the patient leaves 
the operating table, to give a small enema of physiologic saline 
solution. This gives liquid to the patient, who cannot take 
liquids by the mouth for some hours and retain them, and also 
tends to cause more rapid diuresis, and therefore quicker 
efimination of the waste products of the anesthesia. 

If the patient's pulse is not strong after the operation and 
there is no contraindication to increased peristalsis of the 



GENERAL ANESTHESIA 299 

intestines or to contraction of the uterus, injection of post- 
pituitary extract may be good treatment, as this not only 
raises the blood-pressure but promotes diuresis. 

Whether, or not, other stimulation of the heart is needed 
post-operatively, must be decided by the physician in charge 
and by the watchful nurse. As soon as the patient begins 
to vomit or to be nauseated, it is well for him to take small 
draughts of hot water, or if he actually vomits, he should be 
given considerable hot water, which will cause him to get rid, 
either by vomiting or by passing it on to the intestines, of the 
mucus with ether gas which he has swallowed. After he has 
vomited several times and the stomach seems empty, if the 
vomiting persists, it may be advisable to give him a hypodermic 
of morphine and atropine, provided he has not previously had 
it. The dose of morphine need not be large, perhaps not more 
than }{o of a grain, with J150 °f atropine. If he is very 
thirsty and desires ice in his mouth he may have it, but to 
drink ice water or swallow much cold water is inadvisable, as it 
often tends to promote nausea rather than to stop it. If the 
patient cannot take anything into the stomach without feeling 
distention, and he seems to have hard work to breathe, the 
bandages around the abdomen, after a laparotomy, may need 
to be loosened; in fact, abdominal bandages are often put on 
too tight. 

If the patient vomits bile and is terribly nauseated and pros- 
trated, sometimes 5 drops of dilute hydrochloric acid in half a 
glass of water will cause the pylorus to close and check the 
regurgitation from the duodenum, and the vomiting will cease. 
If there is any blood extravasation into the stomach, and 
"coffee-ground" stuff is vomited, or if the vomiting of bile 
continues, or if the patient has swallowed blood which does not 
come up but is retained in the stomach, the stomach may be 
washed out, but this is not often necessary after ordinary 
operations. Sometimes, if there is an irritated condition of 
the stomach, pure olive oil, taken in ounce doses, may stop the 
nausea. At other times eating a lump or two of sugar has 
stopped vomiting. A thin cereal gruel or a thin oatmeal gruel 
will sometimes stay down when other substances are vomited. 



300 THE PRINCIPLES OF THERAPEUTICS 

If the patient does not vomit, the let-alone treatment for a 
number of hours is the best treatment. 

When it is decided that the patient is ready for some nourish- 
ment, cereal gruels are the best; raw egg albumin nonsense 
should be abolished. It is not a food, and is of no value to the 
patient, and to stop nausea and vomiting and to promote the 
patient's welfare carbohydrates are what is needed. A cup 
of coffee, or a cup of tea if the patient prefers, is always a good 
stimulant, or a cup of bouillon may be given. Milk toast or 
malted milk, and soon dry toast crunched (if the patient is 
able, the chewing of starchy foods is of advantage to him) and 
swallowed should be the next food. Soon poached eggs, if all 
goes well, may be added to the diet. 

The great aim of surgeons after operation has been to cause 
the bowels to move. How soon after an abdominal operation 
they should be forced to move is a question that cannot be 
decided by any rule or regulation. The individual and the 
symptoms must be studied, the exact operation and the con- 
ditions present at the operation must be known, and then the 
decision can be made as to what it is best to do in regard to 
moving the bowels. An enema of an ounce of glycerin and an 
ounce of water will evacuate the lower part, at least, of the 
large intestine. Also a saline enema will cause evacuation 
of gas from the colon, and this alone may start peristalsis in 
the small intestine. 

It does not seem necessary to revert to that ancient and 
honorable substance, the compound cathartic pill. Why that 
pill, in most hospitals, must follow an operation can only be 
decided by why it is necessary to put the zodiacal dash over the 
letter R at the head of a prescription. Other drugs will act as 
well if the surgeon will only learn to use them. However, the 
compound cathartic pill is a little better for the patient than 
divided doses of calomel. Of all treatments for the poor duode- 
num, after an operation, that is the worst. If the surgeon decided 
that calomel should be given, let him give the dose he thinks 
advisable (i, 2, or even 3 grains, with 15 grains of sodium bicar- 
bonate) and at the same time a compound aloin pill, and prob- 
ably the results will be perfectly satisfactory. This dribbling 



GENERAL ANESTHESIA 3OI 

irritation of a small dose of calomel frequently repeated, so that 
when the first dose gets there with results the other dose is far 
in the rear, is inexcusable post-operative treatment. 

Whether it is advisable to give divided doses of a saline, 
is certainly a question for careful decision. It would seem 
much better to give such a dose of a saline as it is estimated 
the patient needs for effective action at one time and get through 
with it. On the other hand, without pre-operative purging 
and therefore without as much tendency to distention of the 
bowels, such active cathartic remedies may not be needed. It 
should be recognized that pituitary extracts, hypodermatically, 
are splendid stimulants to intestinal peristalsis. Ergot is 
effective when given intramuscularly. 

Much lauded by many surgeons have been asafetida pills, as 
tending to promote peristalsis by their carminative effect. 
There is certainly no harm in giving a patient asafetida pills. 
On the other hand, a cup of bouillon with onion (a thin onion 
soup) would probably be as effective in causing the downward 
movement of intestinal gas. 

A patient should not go too many hours without the attempt 
to pass urine, as he may be long more or less indifferent to this 
call of nature. Therefore, if, after some hours, he makes the 
attempt and cannot evacuate the bladder, it is better to cathe- 
terize him (carefully and aseptically) rather than to allow vesi- 
cle distention to occur. One catheterization may, under the 
circumstances, be sufficient, while if the bladder is allowed to 
become distended, the patient may have to be catheterized for 
a number of days. The urine should be examined daily for 
several days after the operation, and longer if found abnormal. 

Whatever the operation may have been, even if it is on the 
neck or head, it is inadvisable to sit the patient up on the day 
following, or even the second day following the operation, unless 
he has an unusually good vasomotor tone. Many a patient has 
been gotten upright too soon after an anesthesia, thus causing 
dilatation of his heart and then requiring weeks and even 
months, before his cardiac strength returned. Before a surgical 
patient sits up the vasomotor tone should certainly be approach- 
ing normal. It is absolutely inexcusable, in even a simple appen- 



3 CO THE PRINCIPLES OF THERAPEUTICS 

dix operation, to have a patient up and out in a week, or even in 
nine or ten days. Two weeks is soon enough for such a patient 
to go home. The surgeon- may not have that proud record of 
up and out in eight days, but he has the splendid record of know- 
ing, if anything happens to his patient, that it was not because 
he was too previous. 

It should be urged that the operated patient who does not 
sleep, or does not digest well, or does not have an appetite, or 
does not do some other thing right, should not be given a quanti- 
ty of unnecessary medicine. Surgeons, with all their skilled, 
wonderful and life-saving work, do not always spend much 
time on the study of the action of drugs and of medication. 
They give a few stock mixtures, without knowing what they 
contain, frequently to the disturbance of their patients. When 
medication is necessary the surgeon should either study more 
carefully the art of the physician, or allow a physician to decide 
what the patient should receive. 

When the removal of dressings and drains will cause acute 
pain, the simple expedient of stopping the patient's suffering 
by allowing him to inhale a little chloroform should be consider- 
ed. If, as Sollmann has suggested, a measured teaspoonful of 
chloroform is put on a piece of cotton and the patient allowed 
to hold it to his nostrils and inhale the fumes, his hand will drop 
away before he receives too much, but he will inhale sufficient 
to stop his suffering. Another method is to pour half a tea- 
spoonful of chloroform onto a piece of blotting paper in the 
bottom of a cup, and let the patient hold the cup and inhale. 
The patient's hand will relax and he will cease inhaling as soon 
as he receives enough to dull his sensations. This very partial 
anesthesia will do him less harm than the shock of acute pain 
will do, and as there are no nerves to be cut, he will not be shock- 
ed from the imperfect anesthesia. If the patient's condition is 
too weak for this partial anesthesia, he is also too weak for the 
acute pain of removing some kinds of dressings, and he is well 
prepared to endure the pain by a good sized dose of whiskey 
or brandy, or by an injection of morphine and atropine. 

The Anesthetists Table in the Operating Room. — On a 
table at the side of the anesthetist should be: 



GENERAL ANESTHESIA 303 

i. Tongue forceps. 
• 2. A large needle threaded with strong silk, for holding the 
tongue forward, if it is necessary. 

3. A cork, a piece of rubber, or a mouth gag. 

4. Long forceps and properly made gauze pledgets for swab- 
bing out the mouth and throat. 

5. An emesis basin. 

6. Towels. 

7. Two or three hypodermic syringes. 

8. Atropine sulphate tablets, Hoo an d Koo grain. 

9. Strychnine sulphate tablets, Jio an d }io grain. 

10. Ampules of post-pituitary solution, each i to 10,000, 

11. Ampules of camphor solution each representing 2 grains. 

12. Ampules of ergot. 

13. A mouth suction appliance, as used by dentists. 

A faradic battery, a tank of fresh oxygen, a transfusion 
apparatus, and physiologic saline ready for transfusion should 
be at hand. It is probably rare that in ether or chloroform 
anesthesia oxygen is needed in an emergency, although artificial 
respiration may be necessary. Henderson has shown that 
what is often needed to raise the blood-pressure and prevent 
shock and collapse is really more carbon dioxide, as the patient 
is over-oxygenated, which is the cause of the apnea. 

Recently 1 , Henderson, Haggard and Coburn have especially 
outlined the use of carbon dioxide in emergencies or in shock after 
anesthesia. They believe that post-operative depression is really 
due to insufficient venous circulation. Consequently improve- 
ment must be caused by a return of improved arterial pressure 
and a consequent better venous circulation, and the proper 
administration of diluted carbon dioxide will bring about this 
satisfactory change in circulation. They caution that without 
a reliable method and apparatus the administration of carbon 
dioxide might be dangerous, and if not properly diluted with air 
or oxygen, would be fatal. They have devised a simplified 
apparatus which should be installed in every operating room. 
This apparatus may be studied in the journal named. 

1 The Journal A. M. A., March 20, 1920, p. 783. 



304 1HE PRINCIPLES OF THERAPEUTICS 

These investigators find that within a few minutes after in- 
halation of carbon dioxide has been begun, there is an increase of 
the volume of respiration, even to as much as six times more 
litres of air per minute. This increased respiration deetherizes 
and therefore denarcotizes the patient rapidly and he soon re- 
turns to consciousness. 

After ordinary operations the arterial blood-pressure drops on 
an average perhaps 1 5 millimeters of mercury, but these investi- 
gators find that under the inhalation of carbon dioxide this 
blood-pressure rises rapidly, sometimes from 30 to 40 millimeters 
in four to five minutes, and at the end of fifteen minutes the 
blood-pressure is 10 to 20 millimeters above normal. After the 
termination of the inhalations the blood-pressure returns to 
normal, and in their experiments never fell to the previous low 
levels. 

Patients thus treated after operation quickly have the normal 
color of the skin restored, and seem to have less vomiting. 

These findings suggest the advisability, after an operation is 
complete, of giving a patient, with the proper apparatus, a 
short period of carbon dioxide inhalations. 

Chloroform. — Administration. — Chloroform occurs as a clear 
liquid, with a characteristic odor and a burning, sweet taste. 
It is not used internally as such, except for inhalation to cause 
anesthesia. It is occasionally used externally as a counterirri- 
tant, and it may be used to cause blisters. When given inter- 
nally it is best administered in the form of the official Spiritus 
Chloroformi, the dose of which is small, 0.25 mils (4 minims), if 
the dose is to be frequently repeated, else nausea is caused. 
Larger doses are used to eradicate intestinal parasites, but other 
treatments are better. Spirit of chloroform is given internally 
in cough mixtures for the evaporation which occurs in the 
throat, as such action sometimes quiets an irritating throat 
cough. It also has some carminative action. It should always 
be administered with a syrup, as the syrup of tolu, and taken 
well diluted, as otherwise it causes considerable irritation of the 
throat and stomach. 

Externally the official Linimentum Chloroformi is much used 
to promote counterirritation. When rubbed on the skin a 



CHLOROFORM 305 

rubefacient action is caused ; if the part to which it is applied is 
immediately covered some considerable burning sensations are 
produced. If the part is left uncovered, a cooling sensation is 
caused, on account of the evaporation. 

Action. — Locally on the skin chloroform and ether act simi- 
larly ; both may cause irritation if rubbed on, and if the part is 
covered up, they may cause vesication. On parts exposed to 
the air chloroform may cause a cooling, benumbing sensation. 

The principal action of chloroform after inhalation is on the 
central nervous system and on the circulation. On the nervous 
system it first affects the brain, then the sensory part of the 
spinal cord, next the motor part of the spinal cord, and finally 
the centers of the medulla, especially the respiratory and the 
vasomotor centers. It always causes, as so well shown by 
Hare in his investigations, vasomotor depression, and usually, 
death from chloroform is caused by loss of blood-pressure, and, 
as in shock, the patient bleeds into his own blood-vessels and 
paralysis of the brain and cerebral centers occurs. For this 
reason in heart failure from chloroform more than in almost any 
other poisoning, the inversion of the body, causing gravity to 
fill the blood-vessels of the brain, is the logical immediate treat- 
ment. The body rapidly loses heat under chloroform narcosis, 
therefore the patient should be kept very warm during chloro- 
form anesthesia. 

When chloroform is properly given by inhalation there is 
rarely an excitable stage. There is a sensation of warmth and 
slight irritation in the mouth and throat, the pulse soon becomes 
slower and fuller, but the blood-pressure is lowered. There 
is very little irritation of the air passages as compared with 
that caused by ether. As in ether, dilatation of the pupils 
from profound action of the anesthetic occurs, but it is of more 
serious moment than when the patient is under ether. When 
the dilated pupils do not quickly react to light in chloroform 
anesthesia, the patient is severely narcotized. 

Chloroform is eliminated by the lungs and by the kidneys, 
and the kidneys may be severely injured when they have been 
previously diseased. They are not likely to be as much injured 

as by ether under the same conditions, but it should be remem- 

20 



306 THE PRINCIPLES OF THERAPEUTICS 

bered that ether and chloroform can cause degeneration of the 
kidneys, liver, and heart muscle. It should be emphasized 
that chloroform should never be used as an anesthetic if the 
patient has very low blood-pressure, or the heart is weak or 
irregular, or when there is a possibility that there is serious 
degeneration of the heart muscle. 

One of the most serious dangers during chloroform anesthesia 
occurs from beginning the operation of cutting and severing 
nerves and sensitive tissues before the patient is completely 
anesthetized. The early stage of chloroform anesthesia 
develops so quickly and seems so sleep-like, that operations 
may be begun during this stage, and, in such a condition, when 
the vasomotor tone is reduced, the pain may reflexly act on the 
vagi nerves and the heart may suddenly stop. 

Primarily, in administering chloroform for anesthetic pur- 
poses, it should be remembered that the patient must also 
inhale plenty of air, in fact the more fresh air there is, with 
open windows, or on verandas, or even in tents, the safer is the 
chloroform anesthesia. In a close, hot, stuffy room, chloro- 
form anesthesia is more dangerous than in the summertime 
when the windows can be open. The Esmarch inhaler is 
perhaps one of the best for the drop method of administration, 
as the gauze is some distance from the nostrils. 

The least disturbance of the regularity of the respiration 
should be noted as Hare urges, as before serious disturbance of 
the circulation occurs respiration indications will be given. 

The percentage of chloroform to air should be, for safety, at 
first not more than i per cent., and to produce safe anesthesia 
for operative purposes not more than 2 per cent. Much more 
than that strength of chloroform to air is dangerous. 

Although it has been discussed when chloroform should be 
used in preference to the safer anesthetic, ether, it may be 
repeated that chloroform is better when there are hardened 
arteries; atheroma; very high blood-pressure; serious lung 
trouble; cerebral excitement; convulsions; where muscle 
relaxation is quickly needed for dislocations and for reductions 
of hernia; and when there is Bright's disease. 



CHLOROFORM 307 

Inhalations of chloroform are sometimes given in severe 
whooping-cough spasms; in epileptic and uremic convulsions; in 
eclampsia; and as an anesthetic during parturition. 

During the severe pains in the second stage of labor, if an 
anesthetic is advisable, the patient may be allowed to hold a 
cup with a piece of blotting paper in the bottom wet with 
from a few drops to half a teaspoonful of chloroform. She 
will relax her arm and cease to inhale it as soon as she has 
received enough to quiet her pain. Of course she should not be 
allowed to begin this inhalation of chloroform too soon; it 
should generally be delayed until the child's head is passing 
over the perineum. 

Chloroform inhalations are also often used in the intense 
pain of renal and hepatic colic, and partial anesthesia may 
prevent the necessity of large doses of morphine. It should 
always be remembered, however, that whenever chloroform 
is taken, even in small amounts, slight cardiac disability may 
follow. When large amounts of chloroform are taken by a 
struggling, righting individual, more prostration may follow 
than when the patient quietly inhales it, even if he is 
weak. 

Contraindications. — The contraindications to the use of 
chloroform as an anesthetic are: very low blood-pressure; 
myocardial weakness; generally valvular lesions; obesity with 
possibly fatty heart; anemia; enlarged thymus; adenoids and 
enlarged tonsils; any operation on the head that requires the 
patient's head to be much elevated (one of the dangers of using 
chloroform for extractions of teeth) ; jaundice or any serious 
liver condition; diabetes or starvation, and an increased danger 
of acidosis; after prolonged septic conditions; and serious 
disease of the kidneys. 

Toxic Action. — Sudden death may occur under chloro- 
form anesthesia without any mistake on the part of the 
anesthetist or of the surgeon. Although death occurs more 
frequently under chloroform anesthesia than with any other 
anesthetic, still, with proper care, perhaps no more fre- 
quent, unexpected, unavoidable deaths occur than under other 
anesthetics. 



308 THE PRINCIPLES OF THEEAPEUTICS 

After chloroform anesthesia not only may serious acidosis occur, 
but glycosuria is not infrequent, and fatty degeneration of the 
different organs of the body has been found. But as chloro- 
form should not be administered when the anesthesia must be 
prolonged (another contraindication to the use of chloro- 
form) such pathologic conditions from this anesthetic must 
be rare. 

Although ether must not be used at night in a room lighted 
by gas, or where there is a stove, still chloroform used under 
such conditions may be broken up into chlorine and hydro- 
chloric acid, and even into oxychloride of carbon (phosgene) 
which is a deadly poison, and very serious effects may occur to 
all in the operating room. 

Treatment of Poisoning. — As stated, disturbance of respira- 
tory rhythm should give the warning of over-action of the chlo- 
roform, but in sudden stoppage of the respiration or of the 
heart, the patient should be immediately inverted, to send 
the blood to the head and increase the circulation at the base of the 
brain. It may also be well to tightly bandage the legs from the 
feet up, to force the blood into the upper part of the body and 
the head. Artificial respiration must be done, and should be 
prolonged, if there is any action of the heart whatever. Carbon 
dioxide inhalations, properly given, are advisable. Hypoder- 
matic injections of strychnine, atropine, caffeine, and camphor 
may be given, and either epinephrine or pituitary extract as 
deemed advisable. 

Uses. — Besides its use as an anesthetic, the only good use for 
chloroform internally is in certain kinds of throat coughs. For 
this purpose it may be combined with other substances in tab- 
lets to dissolve in the mouth, giving a slight vapor of chloroform, 
which is soothing to the irritated region. Or, chloroform in the 
form of the spirit may be combined with some cough mixture. 
The dose should be small, not more than 5 to 10 mils to the 100 
mil mixture. 

Chloroform water has been used to disguise bad tasting drugs, 
but this is not a good method ; other preparations are better for 
this purpose. Chloroform has also been recommended for 
intestinal worms, but other treatments are better. 



ETHER 309 

Externally, chloroform in liniments and the official chloro- 
form liniment are valuable for rubefacient effect. 

Ether. — Administration. — Ether is a colorless liquid, has a 
burning, sweetish taste, and contains about 96 per cent, of 
ethyl oxide. 

There is no good use for ether, except as an anesthetic. It 
has sometimes been used internally in the form of the official 
Spiritus Mtheris (Hoffmann's drops), but there is no indication 
for this preparation. Ether has been used externally on the 
skin (when the part to which it is applied is covered up) to 
cause blisters, and (when it is sprayed on the part) to cause 
local anesthesia and freezing, but for both purposes other pre- 
parations are better, such as cantharides in the first instance and 
ethyl chloride in the second. 

Ether may be inhaled through a tube passed through the 
nostrils, when operations must be done on the mouth and face, 
and rectal anesthesia is inadvisable. 

Action. — Externally, especially when sprayed on a part, erher 
causes benumbing and freezing. 

When inhaled, it irritates the eyes, if they are kept open, 
and the face, unless it is covered with vaseline or other fat; it 
irritates the mouth and throat, if it is given too concentrated ; it 
may cause spasm of the larynx, if it is not well diluted with air; 
and many times it causes profuse bronchial secretion, as well as 
profuse salivation. To prevent this increase of liquid in the 
air passages, it is sometimes advisable to give a hypodermic of 
atropine an hour or more before the anesthetic is administered, or 
the atropine may be combined with morphine. But, as pre- 
viously stated under the general discussion of the subject, it is 
not generally wise to combine the action of these drugs with the 
action of ether. 

There is always a stage of excitement more or less in evidence 
at the beginning of ether administration. If the ether is not 
crowded and plenty of air is given the patient, and he is allowed 
to move his arms, and feel that he is not bound down and is not 
going to be suffocated, the stage of excitement is at a minimum, 
in fact, there may be no excitement. Unless the patient is an 
alcoholic or is seriously hysterical, or there is some cerebral 



3IO THE PRINCIPLES OF THERAPEUTICS 

irritation or delirium, a large part of the excitement, disturbance, 
and thrashing in the first stage of ether narcosis is due to fear 
and the sensation of suffocation. 

During the early part of ether anesthesia the face generally 
becomes flushed, the pulse more rapid but fuller and often of 
better tone than .before the ether was started, and during the 
surgical degree of narcosis the pulse slows and the circulation is 
often better than it was previous to the administration of the 
anesthetic. 

At first under ether anesthesia the pupils become slightly 
dilated, but quickly contract if exposed to light, and, during the 
surgical stage of anesthesia, should, on raising the eye-lid, 
quickly contract to light. If they do not do so, the anesthesia 
is, ordinarily, too profound. 

Whether ether is a stimulant to the vasomotor center is a 
question that is still under discussion, but certainly, during 
good ether narcosis when profound anesthesia is not present, the 
pulse is generally regular and the blood-pressure is good. 
However, this does not signify that ether should be given, either 
by inhalation or hypodermatically, or in any other way, as a 
heart stimulant in any kind of heart failure. Other drugs are 
better. 

When ether is too rapidly pushed there may be not only spasm 
of the glottis but also disturbed activity of the diaphragm. 
Hence it is essential that ether be given slowly and gently that 
sudden spasm or stoppage of respiration be not caused. As 
soon as surgical narcosis develops, respiration is generally calm, 
quiet, and regular. The proper amount of ether may have but 
little effect on the respiratory center. 

As pointed out by Hare, if diaphragmatic respiratory move- 
ments are not regular and coordinated, or hiccough occurs, the 
anesthesia is not satisfactory. Sometimes there is this disturb- 
ance when the anesthesia is insufficient, at other times because 
the anesthesia is too profound. The anesthetist must make the 
decision as to which condition is present. In over-doses in a 
too profound anesthesia the respiratory center is depressed and 
death is caused by paralysis of this center. 

The main action of ether is on the central nervous system, 



ETHER 311 

depressing first the higher centers of the brain, then the sensory 
portion of the cord, then the motor tract of the cord, and finally 
the centers of the medulla oblongata. 

Heat is lost from the body, not so rapidly as in chloroform 
narcosis, but more or less continuously, as there is more perspi- 
ration caused by ether, hence care must be taken to keep the 
patient warm. Also it is especially essential that the atmos- 
phere of the room is sufficiently warm that the ether vapor in- 
haled into the lungs is not cold enough to produce chilling of the 
passages. Apparatus has been devised to cause warming of 
ether, as the inhalation of warmed ether is less likely to cause 
pneumonia. The can or bottle of ether may be kept warm in 
a hot water bath. 

Ether is excreted principally by the lungs, and partly by the 
kidneys. 

Toxic Action. — While ether is a much safer anesthetic, es- 
pecially in the hands of a novice, than is chloroform, it should 
not be considered that there is no danger. Sudden heart failure 
and sudden respiratory failure may both occur. Severe throb- 
bing of the blood-vessels and congestion of the brain may occur, 
and cyanosis is not infrequent. These symptoms are especially 
likely to occur with high blood-pressure. 

The paralytic stage of ether is the stage of danger. The 
pupils are widely dilated and inactive to either light or sensation, 
the breathing is very stertorous, the patient is likely to be pale, 
possibly cyanotic, and respiratory failure or cardiac failure may 
occur at this time unless the excess of ether is eliminated. In- 
any such condition the ether must be stopped, and the patient 
allowed to come out of the profound narcotism. He may re- 
quire nothing but the extra amount of air to accomplish this. 

On the other hand, sudden stoppage of respiration or a pro- 
longed sigh often denotes that the patient is insufficiently anes- 
thetized. Also, in some few patients, serious poisoning must 
occur before the eyes are insensitized, and the patient may 
watch the anesthetist for a considerable time during the surgical 
narcosis. To push such a patient to profound narcosis causes 
the administration of too much ether. Other patients are not 
surgically anesthetized unless the pupils are paralyzed. These 



312 THE PRINCIPLES OF THERAPEUTICS 

peculiar cases render the work of the anesthetist harder, and his 
supervision must be the more acute. 

A noisy, stertorous breathing due to vibration of the soft 
palate, is not indicative of serious anesthesia in ether narcosis, 
and, provided the tongue is well forward and the jaw elevated, 
the symptom is not a bad one. 

The treatment of respiratory failure or of cardiac failure, or 
of both, is practically the same as in chloroform poisoning, 
except that, if there is plethora and congestion of the face, the 
head should be raised, rather than lowered. While vasomotor 
depression may be present, it is not as constantly present as it 
is in chloroform narcosis. The hypodermic medication should 
depend entirely upon the condition. Atropine for respiratory 
stimulation is generally needed. Artificial respiration and car- 
bon dioxide inhalation from proper apparatus are especially 
valuable in promoting the elimination of ether from the lungs 
and blood. Rhythmic pulling forward of the tongue, at inter- 
vals of five seconds, may start respiration. 

Vomiting is more frequent after ether than after chloroform 
narcosis. There is more likely to be serious kidney irritation 
after ether than after chloroform, and there may be entire 
suppression of urine. 

Ether is contraindicated by high blood-pressure; seriously 
diseased kidneys; liver disturbances; diabetes; arteriosclerosis; 
atheroma; and in pneumonia, bronchitis, and emphysema. 

Acapnia is a name used by Henderson to signify diminished 
carbon dioxide content in the blood. Henderson says that 
oxygen inhalations should not be given in ether apnea, but that 
oxygen and carbon dioxide gas may be combined for inhalation 
as the anesthetist deems advisable. An efficient method of 
using this combined gas is described by Ewart 1 and a simplified 
method by Henderson and others. 2 

Uses. — The only use for ether is as an anesthetic, and while it 
is generally now considered that the drop method is the best, 
some surgeons and anesthetists believe that it had better be 
administered in greater concentration, provided there is a surfi- 

1 The Journal A. M. A., Oct. 7, 1911, p. 805. 
2 The Journal A. M. A., March 20, 1920, p. 783. 



NITROGEN MONOXIDE 313 

cient amount of air, and provided the ether is warm. The drop 
method may be administered with the Esmarch inhaler, or 
perhaps better with the Allis inhaler, which gives it more con- 
centrated. It takes longer to anesthetize the patient by the 
drop method than by a more concentrated method. The con- 
dition of the patient and the amount of ether required to pro- 
duce surgical anesthesia should be estimated by the anesthetist. 
A long tedious drop method with very slowly developing surgi- 
cal anesthesia is not successful anesthetizing. Therefore many 
patients require a method other than the so-called drop method. 

When an anesthetic is required in colics, spasms, convulsions 
hiccoughs, etc., chloroform is better than ether. 

Nitrogen Monoxide. (Nitrous Oxide) Administration. — 
Nitrous oxide (laughing gas) is a colorless gas, which has a 
slightly sweetish taste. This gas is compressed in metal cyl- 
inders which may be obtained for anesthetic purposes. Its 
only use is to produce anesthesia. 

Action. — When nitrous oxide gas is inhaled for a few seconds, 
mixed with air, an intoxication occurs, the individual becoming 
talkative and laughing, and if much is given, he may become de- 
lirious. If the gas is administered without air, concentrated, in 
a few seconds he is thoroughly anesthetized, the face becomes 
gray or cyanotic, the respiration stertorous, the blood-pressure 
raised, and, if the anesthesia is longer pushed, respiration ceases 
although the heart continues to beat for some time. The tight 
fitting rubber inhaler should be immediately removed as soon 
as stertorous breathing is evident, which, as stated, is in a few 
seconds, and the minor operation should be immediately done, 
as the anesthesia lasts but a short time. 

This anesthetic has been found to be very safe, and it is 
exceedingly rare that death has occurred, unless it has been 
several times repeated for a prolonged operation, and in such a 
case the danger is very greatly increased. This gas alone, with- 
out oxygen, should not be used for anything more than a very 
short opera ton. 

During the anesthesia the face and hands have a very bad 
slate-like look, which soon disappears, however, after a few 
inhalations of air. The anesthesia is due in part to non-oxygen- 



314 THE PRINCIPLES OF THERAPEUTICS 

ation of the blood, carbon dioxide poisoning, and in part to the 
direct action of the gas on the cerebral cortex. During this 
anesthesia, as stated, the pulse becomes fuller, the blood- 
pressure higher, and the heart may throb forcefully. The 
pupils may not lose their reflex action even when the anesthesia 
is profound. 

Some individuals have practically no after effects from a 
short anesthesia with this gas; others are dizzy, have nausea, 
some vaso-depression, and may feel weak for some hours. If 
a patient is anemic, it may take several days before he feels 
as well as usual. 

To prevent over-action and to aid the returning respiration 
after this anesthesia patients should have all the clothing of 
the neck, chest and abdomen loose. There should be no tight 
constriction of any part of the neck or body. Also the patient 
should not take this anesthetic after a meal; the stomach should 
be empty. 

Toxic Action. — The toxic effect is that of failure of respi- 
ration, and the antidote is plenty of fresh air, oxygen inhala- 
tions, and artificial respiration, which should be immediately 
started and prolonged for some time, as the heart fails only 
in very rare instances. Hypodermic injections are generally 
not needed. If anything is given, 'atropine is the drug of 
choice. 

Uses. — The use of this gas alone without oxygen as an 
anesthetic should be limited to very short operations, notably 
extractions of teeth. If teeth are to be extracted, a cork or 
rubber must be placed between the jaws (attached to a strong 
cord so that it cannot be swallowed) , else it may be difficult to 
open the jaw after the patient is anesthetized. 

Nitrous oxide is contra-indicated when there is high blood- 
pressure; myocardial disease; arteriosclerosis; atheroma; and 
when there is any obstruction in the air passages, as adenoids, 
enlarged tonsils, swelling in the larynx, goiter, enlarged thymus, 
or asthma, as in such obstructions from over-action of this gas 
it might be impossible to sufficiently aerate the lungs to save life. 

Nitrous Oxide — Oxygen. — In 1878, Bert began to use a 
mixture of nitrous oxide and oxygen as an anesthetic, first on 



OXYGEN 315 

animals, and then on men, and the anesthetic combination 
proved a success. A number of surgeons, notably Bevan, 
Crile, Halsted, Kelly, and Meyer, found that this anesthetic 
was very satisfactory in major operations, and apparently 
safe, less likely to cause pneumonia, and not likely to cause 
post-operative nausea. One of the great advantages is that 
it produces anesthesia rapidly, and the patient soon recovers 
from the anesthetic, and Crile especially urged that it seemed to 
prevent post-operative shock. This anesthetic, however, does 
not allow as much muscle relaxation, and some surgeons object 
to it in abdominal operations on this account. It is adminis- 
tered by a special apparatus, which allows the anesthetist to 
mix the gases as he finds advisable. 

Very many hospitals adopted this anesthetic and used it 
largely, but many have dropped it and have reverted to the 
long used and satisfactory ether. 

Combinations of these gases with ether have also been urged 
for anesthetic purposes, and the gas administered warmed. It 
requires an anesthetist especially skilled in the administration 
of these combinations for such anesthesia to be safe and 
successful. 

The contraindications to the use of nitrous oxide — oxygen are 
the same as for nitrous oxide, with the exception that with 
these combined gases long anesthesia may be maintained. 

Oxygen. — It may be well to briefly refer to the use of oxygen 
inhalations at this point. Besides administering oxygen with 
nitrous oxide for anesthetic purposes, oxygen gas, passed 
through a wash bottle containing warm water, has been much 
used in the dyspnea of pneumonia and for cardiac stimulation 
in various diseases; but it has been found that plenty of good 
fresh outside air is of as much advantage as oxygen, although 
momentary primary cardiac stimulation may certainly be 
given by inhalations of straight oxygen. A good method is 
to insert the oxygen tube into one nostril, the patient breathing 
with the mouth closed. If more concentration is desired for 
a few minutes the other nostril may be closed during inspiration. 

Sometimes oxygen has been combined with nitrous oxide gas 
both to quiet cerebral excitement, and also to cause circulatory 



316 THE PRINCIPLES OF THERAPEUTICS 

stimulation, but this combination is not much in vogue. The 
real use of oxygen inhalations is in certain kinds of respiratory- 
failure, typically in that from nitrous oxide gas, in illuminating 
gas poisoning, in different kinds of asphyxia, and in combination 
with carbon dioxide gas, as advised by Henderson, in profound 
chloroform and ether narcosis. 

Other Anesthetics. — All the alcohol, chloroform and ether 
mixtures, the so-called A.C.E. mixtures, represent chloroform 
anesthesia, and should be mostly abolished. 

DRUGS USED TO CAUSE LOCAL ANESTHESIA 

Very many minor, and sometimes major, operations are done 
under local anesthesia. Ever since the local anesthetic pro- 
perties of cocaine were discovered, it has been used to anesthetize 
mucous membranes, and injected under the skin to anesthetize 
the soft tissues. Schleich introduced the so-called infiltration 
anesthesia, using cocaine in different strengths which he com- 
bined with morphine and administered in salt solution. Part 
of this infiltration anesthesia is due to distention of the tissues, 
and distention with even cold water will produce a certain 
amount of anesthesia. If the distention from these solutions 
is great, much absorption of cocaine cannot take place. The 
value of morphine as a local anesthetic is so questionable that 
it seems absurd to add it to a solution for local anesthetic 
purposes. 

Sometimes morphine and scopolamine are administered hypo- 
dermatically a sufficient length of time before the operation 
under local anesthesia to obtund the whole central nervous 
system, and then the local anesthesia with cocaine or some other 
local anesthetic is begun. 

The importance of nerve blocking with either water or some 
local anesthetizing preparation has long been urged by Crile, 
and is adopted more or less frequently, especially in operations 
on the jaws. Crile urges such " anoci-association " for larger 
nerves for more serious operations. 

Infiltration anesthesia consists in distending the lower layers 
of the skin with fluid and then puncturing just at the border line 
of this distention, projecting the needle into the next tissue in 



LOCAL ANESTHESIA 317 

order, and so on until the nodular distention is caused over or 
around the region that is to be incised. This method is success- 
fully used by many surgeons in operations for hemorrhoids. If 
deeper tissues must be incised, a second infiltration is done 
below the skin, generally with salt solution containing the local 
anesthetic to be used. Of course distention of a nerve trunk 
will stop sensations below the point of distention. By repeat- 
ing this infiltration anesthesia as the tissues are incised,some 
major operations may be successfully done when it is inadvis- 
able to give a general anesthetic. If after the infiltration the 
tissues are rapidly incised, poisonous doses of the anesthetic 
are rarely absorbed, because the liquid containing the drug 
flows out, and if mopped away, cannot be absorbed by the 
tissues. However, if the anesthetic action of a drug is desired, 
i.e., plus the distention benumbing, enough time must be allow- 
ed for the drug to cause anesthesia, which is generally several 
minutes. The anesthesia of a part, if the solution is not too 
soon evacuated, will last from fifteen to twenty minutes. 

Several efficient local anesthetic drugs are now offered. 
The most important of these are the hydrochloride of cocaine, 
holocaine hydrochloride, beta-eucaine hydrochloride, procaine 
(novocaine), alypin, and quinine and urea hydrochloride. 
Apothesin hydrochloride is another preparation offered. Ben- 
zoyl carbinol, according to Hjort and Kaufmann, 1 is soluble in 
water, not very irritant and a good local anesthetic. 

Sollmann, 2 experimenting with these anesthetics, has shown 
the efficiency to be as follows: cocaine, procaine (novocaine), 
tropacocaine and alypin hydrochlorides have the greatest effi- 
ciency in producing infiltration anesthesia; while beta-eucaine 
hydrochloride has only half the efficiency of these four ; quinine — 
urea hydrochloride only one-fourth that efficiency; and apothe- 
sin one-eighth that efficiency. On nerve trunks he found that 
the greatest amount of anesthesia was caused by cocaine, pro- 
caine (novocaine), and tropacocaine hydrochlorides. Half of 
this efficiency was developed by alypin hydrochloride, and only 

1 Proceedings of the Society for Experimental Biology and Medicine, 1920, 
xvii, p. 79. 

2 The Journal A. M. A., Jan. 26, 1918, p. 216. 



318 THE PRINCIPLES OF THERAPEUTICS 

one-eighth of this efficiency by quinine — urea hydrochloride. 
On mucous membranes Sollmann found that the most efficient 
local anesthetics were cocaine and holocaine hydrochlorides. 
Half this efficiency was produced by beta-eucaine hydrochlo- 
ride, and only one-fourth the efficiency by tropacocaine, alypin, 
and quinine — urea hydrochloride. He found that alkalizing the 
solutions increased the efficiency of the anesthetic on the mu- 
cous membranes, but not for infiltration anesthesia, and there- 
fore suggests that the solutions of the anesthetic salts for mucous 
membrane anesthesia be mixed with equal volume of a half per 
cent, sodium bicarbonate solution, but the alkali should not be 
added to the anesthetic solution until just before it is to be used. 
Sollmann did not find that the addition of epinephrine increased 
the efficiency of the local anesthetic on mucous membranes, but 
it did increase the efficiency for infiltration anesthesia by pro- 
longing the anesthetic action. He recommends that it should 
always be added for infiltration anesthesia, except to tropaco- 
caine. Epinephrine may be added in the strength of i part to 
10,000. He also found there was no advantage in combining 
two or more of the local anesthetics. 

Eggleston and Hatcher 1 have recently made a study of the 
pharmacology of the local anesthetics, and they are right in pre- 
suming that more frequent acute poisoning is caused than is re- 
corded. They studied all reported cases of such poisoning, and 
also made 300 experimental investigations. They studied nine 
of the local anesthetics, and came to the conclusion that the 
relative toxicity from the least poisonous to the most poisonous 
is in the following order, viz.: procaine (novocaine), nirvaine, 
stovaine, tropacocaine, apothesin, cocaine, beta-eucaine, alypin 
and holocaine; procaine having about one-fourth the toxicity 
of alypin and holocaine, as tested on cats' They found that, 
if the circulation and respiration can be maintained for a time, 
these local anesthetics are rapidly destroyed in the liver. 

It must be recognized as a fact that sometimes an ordinary 
non-toxic dose causes excessively unpleasant symptoms, show- 
ing that some patients have a hyper-susceptibility to some of 
these drugs, especially to the cocaine type. 

1 The Journal A. M. A., Oct. 25, iqiq, p. 1256. 



SCOPOLAMINE AND MORPHINE ANESTHESIA 319 

The necessity is certainly emphasized, by the results of these 
investigations, that every time these local anesthetics are used, 
means must be at hand to overcome the effects of over-action of 
the drug. 

Eggleston and Hatcher also emphasize the advantage in 
infiltration anesthesia of adding epinephrine to the solution, 
as it not only prolongs the anesthetic action locally, but also 
prevents rapid absorption of the drug. 

Scopolamine and Morphine Anesthesia. — The combination 
of morphine sulphate and scopolamine hydrobromide (Scopo- 
lamine? Hydrobromidum) came into prominence by being used 
for so-called painless labor, "twilight sleep." This combined 
anesthetic was urged by some few obstetricians, and used in 
some lying-in hospitals, and became so popular as to be lectured 
upon by more or less ignorant lecturers, even to the public in 
department stores at noon hours, and during " twilight sleep" 
was stated by the newspapers and magazines to be the only 
right way for a chilcl to be born into the world. 

This sort of anesthesia during parturition is absolutely 
inexcusable except in an institution with a skilled physician in 
constant charge of each patient subjected to such drugging. 
This combination pushed to the point of anesthesia is probably 
now not frequently used. It certainly often had a bad effect 
on the mother, sometimes prevented normal uterine pains, and 
often asphyxiated the child. 

The method was to inject }£ of a grain of morphine sulphate 
and 3^50 of a grain of scopolamine hydrobromide hypoder- 
matically as soon as the uterine pains of the second stage became 
frequent. Sometimes the scopolamine, and occasionally the 
morphine, was repeated; but as just stated, the treatment is 
not often excusable. 

This same combination has been used to produce benumbing 
of the nervous system before local anesthesia is used. Also, 
at times, morphine and scopolamine, but safer morphine 
and atropine, are given before general anesthesia. However, 
it cannot be too many times urged that a multiplication of 
drugs in anesthesia is not a safe procedure. It is much safer 
for the anesthetist to know that but one stupefying drug is 



$20 THE PRINCIPLES OF THERAPEUTICS 

being used, and that that drug causes certain symptoms in 
over-action, and, also very important, produces certain symp- 
toms in normal and sufficient action. He then knows in what 
condition the patient is, and what to do to increase or diminish 
the activity of the drug used. 

Spinal Anesthesia. — Spinal anesthesia is generally caused by 
injections of tropacocaine hydrochloride, which is an alkaloid 
obtained from coca erythroxylon. It is much less toxic than 
cocaine, and it has the advantage of not having its chemical 
constitution changed by sterilizing. It may be obtained in 
ampules ready for use. The dose, depending upon the size, 
age, and strength of the individual, is from about 0.65 mil to 
1.30 mils of a 25 per cent, solution. The back of the patient 
in the region from the fourth dorsal vertebra to the sacrum is 
painted with iodine, he being in the position for lumbar punc- 
ture, namely, lying on his left side, with his knees drawn up to 
his chin. The spinal puncture is made between the second and 
third, or third and fourth lumbar vertebras. Some fluid is 
withdrawn, the pressure noted, and this fluid may be used 
for any tests deemed advisable, Wassermann or other. Some 
of the warm spinal fluid is then sucked into the syringe which 
contains the solution of tropacocaine from the sterile ampule, 
and this diluted preparation (which should have a specific 
gravity heavier than that of the spinal fluid) is then ready for 
injection. The solution is then slowly injected, and the 
needle quickly removed. The patient should now recline with 
the head and shoulders slightly raised so that there can be no 
possibility of the fluid going beyond the upper dorsal or into 
the cervical regions. The patient almost immediately, in a 
minute or two, feels a numbness of the legs, and of the organs 
and tissues of the pelvic region. It is probably not safe 
to attempt to benumb tissues above the line of the umbili- 
cus, and when the anesthesia reaches that point the patient 
should be made to sit upright, and, if necessary, fluid should be 
withdrawn from the spinal canal. The dose of tropacocaine 
hydrochloride used is from 0.065 t0 °- 10 Gm. (* to r M grains). 

Although some surgeons use this method of anesthesia fre- 
quently, and think that it is comparatively safe, many accidents 



COCAINE HYDROCHLORIDE 32 1 

have occurred, and it must be considered much more dangerous 
than general anesthesia. It has been used mostly for operations 
for hernia, hemorrhoids, plastic operations on the perineum, and 
for some uterine and prostatic operations. If the heart is weak 
and general anesthesia is inadvisable, it probably has its uses. 

A frequent after effect is headache, which may be prolonged 
for several days, and may be very severe. Vomiting has oc- 
curred, and occasionally serious disturbance of the respiration 
has been caused. With great care not to remove too much fluid 
from the spinal canal, and not to force too much fluid into the 
spinal canal if the pressure is high, and to keep the patient at 
rest for some days after the injection, headache may be avoided, 
but it is not an infrequent occurrence, even in spite of care. 

This method of anesthesia seems to prevent shock, and 
certainly precludes an anesthesia pneumonia. The blood- 
pressure generally falls during the anesthesia. 

Cocaine Hydrochloride. — A dministraiion . — The active princi- 
ple of coca (erythroxylon) leaves is cocaine, and the preparation 
that is generally used is the hydrochloride. There is no special 
medicinal excuse for using coca or preparations of coca internally. 

In South America, the home of erythroxylon, the leaves are 
chewed by the natives, both as a stimulant and to prevent 
muscle fatigue, and for such purposes it is certainly efficient. 
How serious the coca habit is with these natives has not been 
determined. 

The hydrochloride of cocaine occurs as colorless prisms or 
as a white crystalline powder, is very soluble in water, and the 
dose is stated as 0.015 Gm. (J£ grain) . There is no good excuse 
for using cocaine internally or hypodermatically for any purpose 
except to produce local anesthesia. When internally adminis- 
tered it readily produces severe poisoning, and if small doses are 
repeated, it quickly causes the cocaine habit. Therefore, to 
repeat, there is no good excuse for using cocaine internally. It 
also should not be used in sprays or ointments for the nose, or in 
sprays or gargles for the throat. It should only be used in the 
nose, throat, or eye by the physician. Prescriptions for cocaine 
should not be given to a patient, except in rare instances. 

Cocaine hydrochloride in solutions is decomposed by more 
21 



322 THE PRINCIPLES OF THERAPEUTICS 

than a few minutes' boiling, but tablets of cocaine dissolved in 
sterile salt water furnish a sufficiently aseptic solution. 

Action. — Externally there is very little action of cocaine on 
the unbroken skin. On mucous membranes it is readily ab- 
sorbed, causes vaso-constriction, blanching of the part, and 
therefore inhibits mucous secretion and prevents rapid absorp- 
tion, provided the solution is strong. If the solution is very 
weak, more of the cocaine may be rapidly absorbed. A i per 
cent, solution is the strength most used for infiltration and a 
2 to 4 per cent, solution for mucous membrane anesthesia. 
The anesthesia is complete in from seven to ten minutes, and 
lasts from ten to fifteen minutes, depending upon the amount 
absorbed. It will not penetrate deeply into the tissues below 
the mucous membrane unless it is injected into them. 

When cocaine is used for infiltration anesthesia, part of the 
immediate anesthetic action is due to the distention from the 
water or salt solution in which the cocaine is dissolved. The 
addition of epinephrine to the cocaine solution lengthens the 
time the parts will be anesthetized, as it prevents rapid absorp- 
tion. Also the addition of the epinephrine allows less bleeding 
when the tissues are incised. As soon as anesthesia is com- 
plete, the parts injected should be quickly operated upon so as 
to release the cocaine in the tissues, allow it to flow externally, 
and prevent much absorption. If much absorption occurs, 
poisoning may result. 

The first effect of absorption is frequently some cerebral 
stimulation; the patient may be rendered talkative, to be later 
followed by some depression. At first the respiratory centers 
are stimulated, the blood-pressure is raised, and the heart is 
somewhat stimulated. Later, depression of the respiratory 
center occurs. Consequently, although cocaine may primarily 
cause stimulation in depression from different drugs or in cir- 
culatory failure, its secondary action is depressant and therefore 
it should never be used for this purpose. When injected into 
nerve trunks it first paralyzes the sensory fibers and finally the 
motor fibers; but it should also be recognized that even plain 
water, from pressure, may have this same effect. The pupils 
are dilated when it is absorbed, or when it is taken internally. 



COCAINE HYDROCHLORIDE 323 

When applied locally to the eye the pupils dilate, and it is 
sometimes used for this purpose by ophthalmologists. It may 
be rapidly absorbed from the stomach, and in weak solutions 
from the nostrils and throat; on the tongue it inhibits the sense 
of taste. From the urethra it may be rapidly absorbed and 
cause poisoning, and hence should rarely be used to facilitate 
the passage of catheters or for other instrumentation, as it has 
frequently caused poisoning when so used. 

Cocaine is partly destroyed in the body and partly slowly 
excreted in the urine. 

Over-action. — It may cause very high blood-pressure, rapid 
heart action, great cerebral excitation, and sometimes convul- 
sions. On the other hand, it may cause the opposite, consider- 
able faintness, prostration, collapse, and respiratory failure. 
While deaths may not often occur from acute poisoning, serious 
symptoms do frequently occur, although such cases are not 
often reported. 

Treatment of Poisoning. — If the drug is in the stomach, tan- 
nic acid and emetics should be given, or the stomach should 
be washed out. Antidotes to the depression are atropine, 
strychnine, camphor, and caffeine ; and the usual treatments of 
collapse, as dry heat, elevation of the feet and legs, and artificial 
respiration, if necessary. 

Cocaine Habit. — This habit was greatly on the increase before 
the State and National laws prevented the sale of cocaine with- 
out the prescription of a physician. Also many nostrums were 
on the market which contained cocaine, and many snuffs and 
catarrh powders contained this vicious drug. In spite of the 
length of time since these laws have been in operation, the co- 
caine habit is still frequently in evidence, and is more serious 
than is the morphine habit. The periods of depression, when the 
desire for the cocaine is in evidence, are terrible, but are im- 
mediately allayed by the usual dose. Sometimes there is an 
unusual stimulation from it, and the individual is loquacious 
and excited; the difference is readily noted between his moods 
of excitement and depression, and the pupils are very evidently 
dilated soon after the drug has been taken. Patients with this 
habit have a great deal of indigestion. 



324 THE PRINCIPLES OF THERAPEUTICS 

Some patients have a combination of the morphine and co- 
caine habits. With such patients the pupils do not react as 
usual to these drugs. 

The treatment is to withdraw the drug as rapidly as possible, 
but as there is likely to be very serious symptoms of depression, 
the patient should always be in an institution, under the best 
medical care. There is no way to cure such a patient except by 
the institutional method. Catharsis and the substitution of 
other drugs for the time being are part of the treatment. 

Uses. — As above stated, there is no good logical use for co- 
caine internally. As a local anesthetic either it or some closely 
allied drug is very valuable. Injections of i or 2 per cent, 
solutions into the tissues will stop local pain, but for anesthesia 
a stronger solution may be needed. Sometimes cocaine is in- 
jected into a nerve trunk to block pain, thus allowing an opera- 
tion to be done painlessly on the region of the nerve distribution. 
Sometimes in ether and chloroform narcosis it has seemed wise 
to block the nerve trunk of the region to be operated to prevent 
shock, Crile 's anoci-association method. 

To anesthetize the mucous membrane for operation, pledgets 
of cotton soaked in the solution of cocaine are pressed firmly 
against the tissues, and the tonsils may be painted with the solu- 
tion. Care should be taken in the nose and throat that these 
solutions are not swallowed. Infiltration anesthesia has already 
been described. 

Beta-eucaince Hydrochloridum. — Beta-eucaine hydrochloride 
is similar to cocaine in its action, but weaker, and it does not 
cause the cerebral or vasomotor stimulation that cocaine does. 
It is more used in ophthalmology because it is less irritant to 
the conjunctiva than is cocaine, and its solutions may be boiled 
without causing disintegration. It may be used in solutions of 
various strength from 2 per cent, for the eye to as much as 10 
per cent, for the nose and throat. As a local anesthetic it may 
be even used in much weaker solutions than 1 per cent. 

Holocaine Hydrochloride, N.N.R. — This drug acts like cocaine, 
and more quickly, and is popular with the ophthalmologists. 
It seems to cause less irritation of the conjunctiva, and is used 
in 1 per cent, solutions. 



ANTIPYRETICS 325 

Procaine, N.N.R. — Novocaine is much used now as a local 
anesthetic in operations on the mouth and teeth. It is less toxic 
in its action than cocaine and acts more quickly, but unless 
combined" with epinephrine, its anesthetic action does not last 
as long as cocaine. This drug is very frequently used for in- 
filtration anesthesia, and in spinal anesthesia. 

Several efficient preparations of this drug are on the market, 
and, also, it may be obtained combined with epinephrine. 
Instructions come with each package as to how to make solu- 
tions of varying strength for different purposes. 

Stovaine and Alypin, N.N.R. are closely allied anesthetics of 
about the same activity as cocaine, but they do not cause 
contraction of the blood-vessels or dilatation of the pupils. 
These drugs are said to be less toxic than cocaine, but the same 
care should be used with any of these local anesthetics as is 
taken in the use of cocaine. 

Apothesine is offered as effective for producing local anesthesia 
both by infiltration and intraspinally. It seems not to be as 
active on the mucous membrane as is cocaine. 

Benzyl Alcohol. —Though Sollmann 1 has found this sub- 
stance to be a local anesthetic on mucous membranes, it seems 
t6 have no advantage over cocaine and cocaine-like preparations. 

Ethyl Chloride. — Ethyl chloride comes in hermetically sealed 
glass containers with an attached atomizing apparatus. When 
this tube is held a short distance from the skin and the spray is 
directed against it the part is quickly frozen and benumbed, 
allowing incisions into boils and abscesses to be made painlessly. 

Ethyl chloride has been used as a general anesthetic, but it 
should not be used for such a purpose. 

Anesthol is stated to be a mixture of ethyl chloride, chloro- 
form and ether. 

CLASS VI 

Drugs Used to Lower the Temperature of the Body 
antipyretics 

Fever may be defined as an abnormal elevation of tempera- 
ture of the body, due to a disturbed state of the system of which 

1 Journal of Pharm. and Exp. Thera., July, 1919. 



326 THE PRINCIPLES OF THERAPEUTICS 

the temperature is a very prominent symptom. To constitute 
a fever this abnormally high temperature must be continued 
for several hours, or if not continuous, at least be intermittently 
repeated. The cause of fever is most frequently an infection. 
Other causes of fever are the absorption, either accidentally or 
by design (injections), of some foreign protein; the absorption 
of some toxins or abnormal protein break-down in the intes- 
tines; or the absorption of broken-down tissue substances from 
injuries; or, finally, fever may be due to some disturbance or 
injury of the head, which causes a mal -function of the heat- 
regulating mechanism or of the thermogenetic centers. 

The types of fever are divided into intermittent, remittent, 
and continuous; the intermittent fever having periods of entire 
absence of fever, the remittent having decided exacerbations 
and decided lowering of temperature but not to normal, while 
a continuous fever is more or less permanently high with, 
generally, variations at different times of day. 

When a fever ends by crisis there is a sudden fall in tempera- 
ture, often to subnormal; muscle relaxation and therefore 
greatly diminished production of heat; generally lowered 
metabolism; weakened heart action; dilatation of the surface 
blood-vessels; great amount of perspiration; increased output 
of nitrogenous waste products in the urine; and general prostra- 
tion. The period of rapid crisis is one of more or less circulatory 
danger, which should be properly combated. But few fevers 
at the present time end by crisis, the majority ending by lysis, 
a gradual reduction of temperature from day to day. This 
kind of temperature reduction does not cause shock to the 
system. The typical reduction by lysis occurs in typhoid 
fever. 

The typical termination by crisis occurs in the old unmixed 
lobar pneumonia. When several types of pneumonia germs 
are associated in the same case, or when these germs are 
associated with streptococcic infection or with the germ of 
influenza, a crisis rarely occurs; the reduction of temperature 
is gradual, by lysis, or there may be very prostrating periods 
of low and even subnormal temperature. 

The exact value of fever in fighting protein intoxication 



ANTIPYRETICS 327 

or infection has not been determined, but it seems to represent a 
normal reaction of the body mechanisms to combat or eliminate 
the poisons and germs. Both theoretically, therefore, and 
practically it is unwise to too actively combat an increased 
temperature, unless the temperature is high enough to cause 
destruction of tissues and therefore is toxic and likely to 
cause death. An intermittent temperature, even if high, is 
well tolerated by the system. A remittent temperature with 
considerable lowering is also for a considerable time well 
tolerated. A continuous temperature over 103 F. soon wears 
out the body and is more or less destructive in itself. A very 
high temperature of 105 or 106 may be well tolerated for a 
short period, but it is soon destructive to tissue, and the exces- 
sively high temperature which occurs in sunstroke very quickly 
destroys the brain centers, therefore it must be actively and 
immediately combated. 

Macleod states that during fever there is more or less con- 
striction of the surface vessels, especially of the extremities. 
This he thinks is compensatory, to send more blood to the internal 
organs which may be in trouble. Therefore it would seem un- 
wise to long administer drugs that reduce the temperature by 
dilating the peripheral blood-vessels and lower the blood- 
pressure, and this has been found to be clinically true. Macleod 
believes that during fever the regulation of heat production to 
heat loss is adjusted at a higher level, but still the mechanism 
responds to stimulation as usual. In other words, the usual 
things that would increase temperature normally will do so 
during fever. There is ,however, an increased heat production 
during fever, and, in continued fever, an interference with nor- 
mal heat loss. Fever patients are more susceptible to cold and 
chilling than are normal patients. Also a patient who is con- 
valescent from a serious acute illness has lost the finer regulation 
of his heat apparatus, and for some weeks more easily has his 
temperature raised and more easily has his temperature lowered, 
i.e., his mechanism is imperfect. 

The waste of tissue during remittent and continuous fever 
is shown by the loss of fat, which breaks down and causes a ten- 
dency to acidosis. For this reason, as now generally recognized, 



$2& THE PRINCIPLES OF THERAPEUTICS 

carbohydrate foods should be pushed during all continuous 
fever processes. There is, also, protein breakdown, as shown 
by the increased creatinin and purin bases in the urine, and 
Macleod says that the diazo reaction of the urine shows an 
abnormal protein breakdown. In many fevers, more in some 
than in others, he states there is a tendency for the tissues to 
retain sodium chloride, and at the same time retain water, 
especially in the blood, and at the time of the crisis more water 
and more sodium chloride are excreted. 

The heat production center, the thermogenic center, seems 
to be in the region of the optic thalami or the corpora striata 
in the brain. Barbour, of the Yale Medical School, has shown 
that applications of cold directly to this center increases metab- 
olism and diminishes heat loss, while the application of warmth 
to these centers increases heat loss and diminishes heat produc- 
tion. This would seem to emphasize the fact of the fallacy 
of the ice cap on the head to combat high temperature, unless 
there is an actual meningeal inflammation, or unless it is applied 
during cold water applications to the body. To continue the 
ice cap on the head with the idea of reducing temperature is a 
mistake. 

If a feverish process is short-lived, the administration of food 
is unimportant, provided the patient receives plenty of water, 
or possibly some cereal gruels; but if the temperature is to be 
prolonged and infection is to be fought, proper food, containing 
all the nutritive elements must be given. If the temperature 
is very high, or the pulse weak, or there is cerebral disturbance, 
digestion will not be good. During fever the hydrochloric 
acid of the stomach is more or less diminished, hence the diet 
must be more or less fluid and easy of digestion ; also it is often 
wise to administer dilute hydrochloric acid after the protein 
meals. 

All infections more or less, and some infections especially 
(typically diphtheria and influenza) tend to lower blood- pres- 
sure and cause prostration, because, probably, they more or 
less directly inhibit the normal activity of the suprarenal 
glands, and suprarenal activity is necessary for normal abdomi- 
nal tone of the blood vessels and for normal digestion. In such 



ANTIPYRETICS 329 

diseases the depressant coal-tar antipyretics should not be given, 
as they depress the suprarenal glands. It is often well in acute 
disease with depression to begin early the administration of 
small doses of suprarenal extracts. 

As above stated, it is necessary in all prolonged fever pro- 
cesses, and especially when there has been diminished nutrition 
or a prolonged period of low food intake, to push carbohydrates, 
as acidosis is the final outcome in many acute diseases, and it 
may be prevented by such foods. 

In reducing temperature in continued fever, all of the side 
disturbances which cause increased temperature should be re- 
moved or prevented. Toward this end the patient must be 
kept cool by not being over-covered ; by electric fans, if possi- 
ble ; and by the windows being open ; or the patient may be on a 
veranda, if the weather is warm. Cool drinks and plenty of 
water should be given; proper movements of the bowels should 
be encouraged ; the patient should not be disturbed mentally or 
physically; he should be allowed to sleep, if he is sleeping quietly, 
without unnecessary awaking to give food or medicines, or for 
any other purpose. The temperature will be lowered by these 
methods alone. 

It is important that the patient should receive plenty of 
water, and, if he is too stupid to ask for it, he should be given a 
drink at least once an hour, unless he is quietly sleeping. If he 
wants ice to dissolve in his mouth, he should be allowed it. 
Cool water, or allowing ice to dissolve in the mouth, is better 
than drinking ice water. Sometimes it is advisable to give a 
soothing drink, as barley water. The patient should also have 
either lemonade or orangeade, or he may chew and swallow 
orange pulp. These fruit juices stimulate the flow of saliva, 
and are valuable foods for fever patients. 

The height of the temperature is often increased by secondary 
infections and by the absorption of protein poisons or of the 
toxins of secondary infections. A large part of these causes may 
be prevented by care. Every fever patient should have the 
bowels properly moved, best at first with calomel perhaps 
followed by a saline, or with castor oil, or with some other 
effective cathartic. The bowels should then move daily, either 



330 THE PRINCIPLES OF THERAPEUTICS 

by a laxative or by an enema of glycerin and water, unless 
there is some contraindication. By this care of the bowels 
secondary bowel toxemias will not occur. 

If there is any localization of suppuration, or of exudate, or 
of any pathogenic condition that needs attention, it should be 
properly treated constantly and sufficiently during the con- 
tinuous fever. This means that the local condition of the 
throat should be cared for in diphtheria, even if sufficient antitoxin 
has been injected. The tonsils, throat, and mouth should be 
kept clean by gargling if possible, or by spraying, or swashing. 
Pyorrhea regions should be kept clean with some antiseptic 
solution, the one deemed best by the physician. 

The mouths of patients who have fever should be carefully 
watched, and especially in young children and old people. The 
greater the debility and the greater the fever, the more the 
mouth requires attention. The teeth and gums should be 
properly cared for several times a day, and the mouth should 
always be rinsed before food is taken. Normal physiologic 
saline solution or saturated solutions of boric acid, or some pleas- 
ant alkaline mouth wash may be used. If the lips are dry they 
should be softened with a boric acid ointment, or with glycerin 
and water equal parts, or with white vaseline. If canker sores, 
or cracks, or fissures occur, they should be swabbed, twice 
daily, with peroxide of hydrogen solution, full strength, and 
swabbed several times a day with a potassium chlorate solution. 
Occasionally it is necessary to use the nitrate of silver stick to 
hasten the healing of such a condition. The tongue should be 
gently cleaned , if it is heavily coated ; but with proper care of the 
mouth and of the bowels, the tongue will usually remain in good 
condition. Scrubbing of the mucous membrane of the mouth 
or tongue should not be allowed. Proper care of the mouth 
will generally prevent glandular swellings in the neck and in- 
fection of the thyroid and parotids. 

In short attacks of high temperature the patient may be 
made more comfortable by some antipyretic drug; such treat- 
ment can do no harm and will do a great deal of good by hasten- 
ing the expected defervescence and the sweating stage, as 
typically occurs in intermittent fever attacks. Also in the 



ANTIPYRETICS 33 1 

myalgias, headache and other disturbances of acute tonsillitis, 
or in the beginning of a fever, as scarlet fever, measles, or 
typhoid fever, a few doses of a coal-tar antipyretic, or a syn- 
thetic antipyretic, or a salicylic acid preparation is not unwise 
and is good therapeutic treatment. But in any continued fever, 
after the first two days antipyretic drugs are generally better 
omitted; to reduce fever reliance must then be on cold applica- 
tions, namely, on hydrotherapy. The very high temperature 
which occurs in sunstroke must be rapidly reduced by proper ice 
and water applications. In these instances drugs will not act, 
and reliance must be on measures that quickly abstract heat. 

During continuous fever all drugs that tend to increase the 
temperature, as caffeines, atropines, strychnine, etc., should not 
be administered unless positively indicated. If, on the other 
hand, some cerebral stimulation is advisable, or some circula- 
tory stimulation is needed, especially in the morning, a cup of 
coffee is good treatment. When the temperature tends to be 
too low, or there is prostration, or there is too much prespiration 
atropine and strychnine are valuable, and suprarenal should 
be given. It should also be noted that hypnotics, if they are 
needed, will always cause some depression and some lowering 
of the temperature. 

The antipyretic drugs are all more or less analgesic; they will 
stop certain kinds of pain. They will not stop acute inflam- 
matory pain, nor the pain of a colic, but they will stop the aches 
and pains of ordinary infection. Whether they should be given 
long for such a purpose depends on the circulation and the 
disease. The great over-use at the present time of antipyrine, 
acetanilid, and more especially aspirin, for every ache and pain 
and every other disturbances that may occur to the individual 
is a serious therapeutic and physiologic mistake, and many 
individuals are suffering from the over-use of aspirin. Aspirin 
is a depressant to the suprarenals, and more or less depressant 
to the heart, and a patient who has been taking a great deal of 
aspirin is not well fitted to combat any acute infection or dis- 
turbance that he may develop. 

The point at which temperature should be actively combated 
in continuous fever varies with the opinion of different clini- 



332 THE PRINCIPLES OF THERAPEUTICS 

cians. It is well to consider that a temperature above 102 in 
typhoid fever is undesirable, but a temperature below that 
need not be much combated. Continuous fever of 102 , or 
over, will cause degeneration of the liver, kidneys, muscles, and 
heart. Therefore, a temperature of 102 , or over, should be 
kept down by proper hydrotherapeutic measures. 

To properly study the temperature it need hardly be stated 
that the thermometer reading must be taken at the same 
hour each day, and in the same manner, and if placed in the 
mouth, the patient must be watched lest the mouth is opened 
and the consequent reading be incorrect. If the axillary 
temperature is taken, the arm should be firmly held in place, 
after the moisture in the axilla has been removed, else the arm 
relaxes and the temperature reading, consequently, will be 
incorrect. Only in exceptional instances is it advisable to 
take rectal temperatures. It is a nuisance, and unpleasant 
to adult patients, and often the reading is higher than is ex- 
pected, even when the patient is apparently convalescent, and 
hence may cause more mental disturbance to physician, nurse, 
and patient than is necessary. Even in young children the 
rectal temperature is not constantly necessary ; the thermometer 
may be placed in the folds of the groin with the leg held tightly 
to give the correct reading. 

The urine should be more carefully watched in fever than has 
been done, and many a lumbago, or myalgia of the lumbar 
region, which occurs with most infections, is really due to 
some kidney congestion, and albumin will frequently be found 
in the urine of such patients. 

The coal-tar antipyretic drugs are acetanilid, antipyrine, and 
acetphenetidin (phenacetin) . While there are very many 
newer coal-tar and synthetic drugs that will reduce temperature, 
these three are still the most important and serviceable, and 
are as safe as any coal-tar drugs. Lately acetylsalicylic acid 
(aspirin) has become the most used drug to stop headaches, 
myalgias, and neuralgias; to abort colds; and, in fact, to abort 
most anything to which human flesh is heir. It does not 
reduce temperature as much as the coal-tar drugs. Its action 
is that of a salicylic acid, only more depressant than salicylic 



ACETANILID 333 

acid. Acetylsalicylic acid will reduce the temperature some- 
what in fever, but not much in normal individuals, as shown 
by Barbour and Devenis. 1 These investigators also showed 
that the loss of temperature under acetylsalicylic acid is due to 
increased heat elimination, and that it also decreased the pulse 
rate. Barbour and Herrmann 2 have found that "antipyretic 
drugs increase the blood content of dextrose, a substance itself 
often exhibiting temperature-reducing properties when intro- 
duced from without." 

Acetanilid (Antifebrin) . — Administration. — Acetanilid occurs 
as a colorless, crystalline powder, has a slightly burning taste, 
and is very slightly soluble in water. The Pharmacopceial 
dose of 0.20 Gm. (3 grains) is often too large, unless but a 
single dose is administered; 0.10 Gm. (1 J^ grains) to be repeated 
once or twice, is a better dose. When this coal-tar preparation 
was first offered, the dosage used was much too large. 

Combining any coal-tar product with an alkali, as sodium 
bicarbonate, seems to more or less prevent its depressant action. 
The addition of caffeine to these drugs has been shown not to 
decrease the depressant action on the heart, but in many 
instances rather to increase it. However, a combination with 
citrated caffeine is often of value in some kinds of myalgias, 
and also in headache. Many pharmaceutical preparations of 
acetanilid, acetphenetidin, and antipyrine are offered which are 
effervescent, and very many similar headache nostrums are sold. 
The following combination makes an effervescing mixture: 

I* 

Acetanilid 0.10 Gm. 

Citrated caffeine o . 05 Gm. 

Sodium bicarbonate 1 . Gm. 

Tartaric acid 1 . Gm. 

Make one powder. Place in waxed paper and keep dry. 

Dissolve in half a glass of water and take as it finishes effervescing. 

If acetphenetidin is desired instead of the acetanilid, the 
dose of acetphenetidin in the above powder would be 0.30 Gm. 
If antipyrine is desired, the dose would be 0.50 Gm. 

1 Archives Internal Medicine, Dec, iqiq, p. 617. 

2 Proceedings of the National Academy of Sciences, Vol. 6, March, 1920, p. 136. 



334 THE PRINCIPLES OF THERAPEUTICS 

Action. — Acetanilid is the most active of the three official 
coal-tar antipyretics, but if the dose is small it is a perfectly safe 
drug to use for a few doses in the beginning of a feverish process, 
or to stop headache and myalgias. 

Until the drug laws required that when a preparation con- 
tained acetanilid it should be so stated on the label, acetanilid 
was the most used drug in nostrums and proprietary mixtures 
because it was very active, and because it was very cheap. 
After many deaths had occurred from acetanilid, and the name 
of this drug was required to be placed on the label of prepar- 
ations that contained it, and the patent was removed from 
acetphenetidin (phenacetin) , phenacetin was largely substituted 
in these nostrum and proprietary preparations. This was an 
improvement, as phenacetin is less debilitating and less depres- 
sant than acetanilid. Still, when any one of these coal-tar 
preparations is frequently taken for recurrent pains, or for 
other reasons, not only will the heart be weakened and the 
blood-pressure lowered, but more or less anemia develops. 
Rarely from acetanilid or acetphenetidin, but not infrequently 
from antipyrine, will kidney irritation be caused, if the drug 
is long repeated. 

There seems to be more or less of a tolerance acquired for any 
one of these coal-tar preparations, and there may even be an 
acetanilid habit, much as there is an acetylsalicylic acid (aspirin) 
habit, but there is no healthy future for the long repetition of 
any one of these drugs. 

The proportionate doses of these drugs to produce the same 
lowering of temperature and analgesic effect are about as 
follows : 

Acetanilid o. 10 Gm. (i}4 grains) 

Acetphenetidin o . 30 Gm. (5 grains) 

Antipyrine o . 50 Gm. (7)^ grains) 

Externally acetanilid has no action except that of a mild anti- 
septic, and it is not now much used for that purpose. It is not 
irritant to mucous membranes, and is absorbed rather rapidly 
from the stomach. The blood-pressure is always lowered and 
the heart quieted by acetanilid, also it seems to have a sedative 
action on the brain. 



ACETANILID 335 

The temperature is always lowered in fever by ordinary 
doses, probably due to action of the drug on the thermogenetic 
centers in the brain. It also promotes perspiration, largely by 
dilating the peripheral blood-vessels; therefore heat loss is also 
increased. 

The drug seems to have a particularly dulling action on the 
sensory nerves, but the motor nerves are but little affected, al- 
though there is general muscle weakness after even ordinary 
doses of acetanilid. For this reason, a patient who takes this 
drug, even for an ordinary headache, should be at rest, and 
should not go out or be subjected to physical strain or to cold, 
as he is likely to become chilled or to have cardiac depression. 

It may be partially oxidized in the body, but is principally 
excreted by the kidneys in the form of paramidophenol sulphate. 
If large doses have been taken the urine may become darkish 
brown in color on exposure to the air. 

Over-action.- — The over-action is that of depression, perhaps 
collapse, sometimes cyanosis. Often there is a clammy perspi- 
ration. The blood-pressure is low and the heart is slow but 
made rapid by the least exertion. There may be some chemical 
disturbance of the hemoglobin, and methemoglobin may be 
produced, resulting in decreased power of oxygenation. 

Toxic Action. —The toxic action of this drug is simply an 
exaggeration of the symptoms of over-action. There may be 
dyspnea, absence of radial pulse, and very serious heart failure, 
i.e., collapse. Death occurs from failure of the respiration. 

Treatment oj Poisoning. —The treatment is to remove the 
drug by washing out the stomach or by emetics, if it is consid- 
ered that some of the drug is still in the stomach. Surround 
the body with dry heat; give such hypodermic stimulants as 
strychnine, atropine, and pituitary extract; coffee by the mouth 
or rectum; and large doses of sodium bicarbonate. 

In chronic poisoning from this drug, or any coal-tar drug, 
the treatment is, of course, to stop the drug, let the patient rest, 
push nutrition, give tonics especially iron, and, 'often, digitalis. 
Prolonged rest and good nutrition is the main treatment. 

Uses. — Acetanilid is used for two purposes only, first, to lower 
temperature, and second, to stop pain. 



336 THE PRINCIPLES OF THERAPEUTICS 

This drug is used less frequently to meet the first indication 
than are other drugs, at the present time. Acetylsalicylic acid 
has practically displaced acetanilid, as being considered safer, 
and perhaps acting sometimes as well. Acetanilid, however, is a 
very valuable drug with which to lower temperature, and when 
properly used is the best, although the dose is much smaller than 
was once considered proper. Acetylsalicylic acid is somewhat 
stimulant to the brain, as all preparations of salicylic acid, but 
it is not as perfectly safe for the heart as it was thought to be. 
However, to use any antipyretic very frequently or very long 
is a mistake. If the temperature is too high for more than a 
day or two, cold water applications represent the proper treat- 
ment. To reduce temperature, acetanilid may be ordered as 
follows : 

Acetanilid o . 30 Gm. 

Sodium bicarbonate 3 . Gm. 

Make 3 powders. 

Take one powder every three hours, if needed. 

When this amount of acetanilid has been taken and the tem- 
perature remains high, other treatments should be instituted. 

Acetanilid, as other coal-tar products, has a decided anal- 
gesic effect when the cause of the pain is general toxemia; a 
local congestion; a muscle strain; or a headache due to eye- 
strain, or, perhaps, due to pituitary congestion. Sometimes 
the pains of dysmenorrhea, and some forms of neuralgia are 
stopped by acetanilid. It will not stop acute inflammatory 
pain or colics, and should not be administered in such con- 
ditions. When used as an analgesic the dose should not be 
large, and it should not be frequently repeated; also it [should 
not be used every time the patient has a pain somewhere. Aspi- 
rin has now entirely superceded this drug, and it is taken 
every time there is an ache or a pain or a possible cold 
developing. 

Acetphenetidin (Phenacetin) . — A dministration. — Acetphe- 
netidin occurs as white crystalline scales or as a fine crystalline 
powder, has a slightly bitter taste, and is practically insoluble 
in water. The dose is 0.30 Gm. (5 grains). 



ANTIPYRINE 



337 



Action. — This drug has similar activities to acetanilid but it 
is much less likely to cause cardiac depression or poisoning, 
unless the dose is very large. 

This drug is used for the same purposes as is acetanilid. A 
useful combination is as follows: 

Acetphenetidin i . 50 Gm. 

Citrated caffeine 0.25 Gm. 

Phenyl salicylate 1 . 50 Gm. 

Make 5 powders. Take one powder every three hours. 

This combination is especially efficient in stopping the aches and 

pains of an acute infection, as tonsillitis, measles, or influenza. 

Such dosage, as above suggested (modified for children), will 

not cause depression, and will lower temperature and stop the 

myalgias. 

Antipyrine {Phenazone) . — Administration. — Antipyrine oc- 
curs as a white crystalline powder, has a slightly bitter and, 
in solution, nauseating taste, and is very soluble in water. The 
Pharmacopceial dose is 0.30 Gm. (5 grains) . This dose is rather 
small. The drug may be administered in capsules which may 
be uncapped before swallowing, which obviates the disagreeable 
taste; or it may be administered in solution. 

Action. —This drug has often been used in the mouth and 
throat as an antiseptic, either in spray or gargles, in such a con- 
dition as whooping cough. It is rapidly absorbed from the 
stomach, and has the same activities as acetanilid, with the 
exception that it seems to cause more perspiration, and is less 
likely, in full doses, to cause cardiac depression. It seems to be 
more analgesic in neuralgias, neuritis, and in pains emanating 
from the spinal cord than is acetanilid, and large doses have been 
frequently given, on this account, in locomotor ataxia. Large 
doses may cause a methemoglobin to be formed, and it may 
cause some irritation of the kidneys during its excretion. 
Antipyrine may cause an urticaria from irritation of the 
duodenum. 

Over-action. — The over-action is that of depression, occasion- 
ally cyanosis, but generally the only symptom of over-action is 
too profuse, prostrating and continued perspiration. 

The treatment of over-action or of poisoning is the same as 
22 



338 THE PRINCIPLES OF THERAPEUTICS 

that for acetanilid, except that for a long time large doses of 
alkalies should be administered. 

Uses. — Antipyrine has frequently been used as an antipyretic, 
and as such is valuable. The best dose is 0.50 Gm. to 1 Gm., 
repeated in four or five hours, if deemed advisable. It has not 
been used as much for headaches as the other two coal-tar drugs, 
but large doses have been given for the pains of locomotor 
ataxia, and patients who receive these doses for some time seem 
to become tolerant to the drug and have no depression from it. 
However, it is not always successful in stopping that kind of 
pain. 

Antipyrine has often been used to relax muscle spasm; it 
seems to diminish reflex irritability of the nerve centers. For 
whooping cough it is one of the most valuable treatments, and 
the dose for a child is 0.05 Gm. (a little less than a grain) for 
every year of the child's age. As it is disagreeable, it is well 
ordered in plain water, and administered in some drink, as 
lemonade or orangeade. The above dosage may be given three 
or four times in twenty-four hours, depending upon the number 
of the paroxysms of coughing. Older children may take the 
drug in capsules. It is always well in whooping cough under 
any treatment, but especially with the treatment with antipy- 
rine, to give digitalis coincidently, in the proper dose for the 
age of the child. 

At times antipyrine has seemed to be as efficient a treatment 
in stopping muscle twitching in chorea as are bromides, but 
both treatments are depressant, and these children generally 
require forced nutrition. 



CLASS VII 

Drugs and Preparations that are Specific 

A specific treatment in medicine means a treatment that has 
positive antidotal activity against the disease or condition 
present. The few specifics known to medicine are listed in the 
classification. A description of a few drugs not described 
under more appropriate headings are here given. 



MERCURY 339 

MERCURY 

Mercury (Quicksilver). — Administration. — Metallic mercury 
is used only in one of its official preparations, the most impor- 
tant of which are: Massa Hydrargyri (blue mass, blue pill) 
which is an ancient preparation that is not needed, as calomel 
will act as well; Unguentum Hydrargyri (mercurial ointment) 
and Unguentum Hydrargyri Dilutum are used externally for 
inunctions and in certain parasitic diseases of the skin. 

Calomel (Mercurous Chloride). — Description. — Calomel is a 
white powder, insoluble in water. It is used internally mostly 
for its cathartic action; occasionally for its general action as 
an antisyphilitic; sometimes, in small doses, as a diuretic in 
cardiac dropsy when combined with other drugs. Calomel 
should, however, rarely be used for systemic purposes as it 
readily causes salivation. Also there is frequently found an 
idiosyncrasy against mercury, especially calomel, stomatitis 
occurring in these patients with ordinary cathartic doses. 

Calomel is frequently given in small doses, as 0.006 Gm. 
(Mo grain) repeated every half hour for ten doses, for a laxative 
and so-called antiseptic effect in the bowels. Such treatment 
is rarely advisable. Other antiseptics are better, and if calomel 
is needed, it is much better administered in a full dose suitable 
for the individual. The cathartic dose of calomel is from 0.05 
to 0.25 Gm. (about 1 to 4 grains) and it is often best given 
coincidently with aloin. If it is given at night, on the following 
morning a saline should be given, unless deemed inadvisable. 

Calomel is an ingredient of the Compound Cathartic Pill, an 
ancient preparation which is not needed. 

Yellow Iodide of Mercury {Mercurous Iodide), — Descrip- 
tion. — Protoiodide of Mercury is a bright yellow amorphous 
powder, insoluble in water. This drug is often used for system- 
ic action in a dose of 0.01 Gm. (}i of a grain). 

Red Iodide of Mercury (Mercuric Iodide). — Description. — 
Biniodide of Mercury occurs as a scarlet red amorphous powder, 
which is practically insoluble in water. It is used only for 
systemic purposes, and the dose is 0.003 Gm. (J"^o grain). 

The official Hydrargyri Oxidum Flavum and Hydrargyri Oxi- 



340 THE PRINCIPLES OF THERAPEUTICS 

dum Rubrum (Red Precipitate) are not used internally, bat are 
used externally in the form of ointments. The official Unguen- 
tum Hydrargyri Oxidi Flavi, represents 10 per cent, of the drug. 

The official Hydrargyrum Ammoniatum (White Precipitate) 
is used only externally as an ointment, and the Unguentum 
Hydrargyri Ammoniati represents 10 per cent, of the drug. 

Hydrargyri Salicylas occurs as a slightly yellowish or pinkish 
powder, is practically insoluble in water, and has been used in 
suspension for intramuscular injections in syphilis. 

Corrosive Sublimate {Mercuric Chloride). — Description. — 
The bichloride of mercury occurs in crystalline masses or as a 
white powder, and is soluble in water. The dose is 0.003 Gm. 
(3^20 °f a g ram ) • It is used externally as an antiseptic wash in 
solutions from 1 part in 500 to 1 part in 10,000, or even weaker. 
The official tablets for antiseptic purposes to be dissolved in 
water (the amount depending on the required strength) are 
termed Toxitabellce Hydrargyri Chloridi Corrosivi (Poison 
Tablets of Corrosive Sublimate). 

Action. — Almost the only used preparation of mercury for 
external antiseptic purposes is corrosive sublimate. If the 
solution is used too strong, severe irritation of the skin and 
the parts to which it is applied is caused. If there is a large 
absorptive surface, or if the solution remains too long in a 
cavity which has been washed with the solution, systemic poison- 
ing may occur. Corrosive sublimate antiseptic solutions have 
been used too much, and especially too frequently on fresh wounds 
as such treatment tends to prevent healing. 

There has recently been offered a new salt, a combination of 
fluorescein and mercury, termed "Mercurous Chrome — 220." 
A description of this drug and its uses as a germicide is offered 
by Young, White and Swartz, 1 who present their conclusions 
that this preparation has great germicidal value, and in a solu- 
tion of 1 to 1,000 will kill the bacillus coli and the staphylococcus 
aureus in urine in one minute, and that this preparation may 
remain in the human bladder in 1 per cent, solutions from one to 
three hours without irritation. Though they find the drug of 
value as a local genitourinary antiseptic, its greatest value seems 

1 Journal A. M. A., Nov. 15, iqiq, p. 1483. 



MERCURY 34I 

to be as an antiseptic injection in infection of the bladder and 
the pelvis of the kidney. 

Mercury in various forms in oily or fatty preparations may be 
rubbed into the skin, be absorbed, and cause systemic action, 
and even the insoluble preparations are used for this purpose, 
but they are probably not as satisfactory as the carefully pre- 
pared mercurial ointments. 

Internally, except in minute doses, the soluble mercurial 
preparations, and typically mercuric chloride, are corrosive 
poisons. Calomel is, ordinarily, not absorbed in the stomach, 
but is absorbed from the intestines, and if it does not quickly 
cause catharsis, may cause symptoms of mercurial poisoning, 
but not of corrosive poisoning. 

The systemic action of mercury is shown by a tendency to 
looseness of the bowels, and sometimes slight diuresis. Soon, 
if the dose is too large, or there is a hypersusceptibility of the 
patient, salivation is caused, with, if the drug is not quickly 
stopped, softening of, and bleeding from, the gums, loosening of 
the teeth, and general stomatitis. Mercury may irritate or 
slightly stimulate the liver, but it has not been shown that the 
bile is increased in amount. If brisk catharsis is caused by' 
calomel or by any other form of mercury, the liver is relieved 1 
by the improvement of the portal circulation, and by the elimi- 
nation from the bowels of substances that, during constipation, 
are re-absorbed and must be again detoxicated by the liver and 
re-excreted in the bile. Hence the liver is often improved by 
catharsis caused by a mercurial salt. 

There is no excuse for administering mercury internally 
except as a purge (and for that purpose calomel is the best prep- 
aration) and for the treatment for syphilis. Syphilis cannot 
be successfully treated, with our present knowledge, without 
the use of mercury in some form, either by inunctions, by intra- 
muscular injections, or by the administration internally of one 
of its salts, as the yellow iodide, the red iodide, or sometimes 
corrosive sublimate. 

Mercury is excreted in the form of an albuminate both by the 
intestines and by the kidneys, and the kidneys may become irri- 
tated and inflamed, if the dose has been large. If mercury has 



342 THE PRINCIPLES OF THERAPEUTICS 

been given for some time it will not all be excreted until some 
weeks after the last dose has been taken. When it is necessary 
to give mercury for a long time, as in syphilis, it is often advis- 
able to give Turkish baths, or electric light baths, or hot air 
treatments, to promote elimination and to prevent too much 
accumulation of the mercury in the tissues of the body. 

Over-action. — Over-action of mercury is shown by loss of 
appetite, diarrhea, perhaps gastrointestinal inflammation, 
salivation, muscular weakness, and loss of weight. When there 
is an abnormal susceptibility to the internal administration of 
mercury, as shown by salivation and loose bowels, and when it is 
necessary to push this drug internally rather than by other 
methods, some drug may be given to control the laxative action 
of the mercury, and mouth washes should be used constantly to 
prevent salivation and inflammation of the gums. Potassium 
chlorate mouth washes are perhaps the best for this purpose, 
although various astringents are used, as tannic acid 
preparations. 

Chronic mercurial poisoning is not frequent, but can occur 
in those who handle mercury, as artisans in mirror, thermometer 
and barometer factories. The symptoms are likely to be loss of 
appetite, emaciation, indigestion, disagreeable breath, soreness 
of the gums, sometimes neuritis and muscular weakness, and 
progressive anemia. There may be eruptions on the skin, and 
there is likely to be albuminuria. 

Toxic Action. — Acute poisoning by mercury (generally by 
corrosive sublimate taken internally by mistake or by intent) 
gives the typical symptoms of corrosive poisoning. This is 
described under poisons, and the treatment is especially out- 
lined on page 761. Occasionally the vapor of mercury has 
caused acute poisoning. The symptoms are those of multiple 
neuritis and paresis. 

Uses. — There is no internal systemic use for mercury except 
in the treatment of syphilis. Whenever mercury is used for 
this purpose, the nutrition should be watched, and the patient 
should not be allowed to lose his appetite or become emaciated 
during its administration. If the kidneys are diseased, mercury 
in any form must be used with a great deal of care, if used at all. 



PREVENTION AND TREATMENT OF SYPHILIS 343 

Also, when mercury has been given for some time, the thyroid 
gland is likely to become more or less inhibited in its activity, 
and this may be one of the reasons that, after syphilis and the 
treatment of syphilis, sclerosis of so many of the tissues of the 
body is likely to occur, i.e., conditions which are termed tertiary 
syphilis. 

PREVENTION AND TREATMENT OF SYPHILIS 

Before discussing the treatment of syphilis, the methods for 
successful prevention of venereal diseases may be itemized, 
without discussion, as: 

1. Education in schools and colleges, and by social service 
instruction. 

2. Dissemination of the knowledge of the best methods for 
the prevention of this disease when opportunity for infection 
has occurred. 

3. Compulsory reporting of individuals infected by these 
diseases. 

4. The insistence that an individual must be treated until 
he is cured. 

5. The restraint of public carriers. 

The moral end of this discussion is left for other teachers and 
the details of carrying out the above suggestions are left for 
papers and books treating of these diseases. The treatment of 
gonorrhea and of venereal sores is outside of the scope of this 
book, but the treatment of syphilis depends so much on the 
action of drugs that the management of that disease is here 
outlined. 

The menace of syphilis is at the present time very great as 
this infection is on the increase in civilized communities. 
The danger of the spread of the infection has increased 
because modern treatment prevents secondary symptoms 
occurring, and the individual thinks he is cured, and the physi- 
cian loses sight of his patient. Consequently, the uncured 
man or woman may transmit the disease to others, and also may 
in after years develop syphilitic disease in any part of the body. 
There may be paresis, locomotor ataxia, arteriosclerosis, liver, 



344 THE PRINCIPLES OF THERAPEUTICS 

kidney or stomach disease, all due to the uncured syphilis. A 
small proportion of individuals acquire syphilis ex tra-geni tally, 
but perhaps not more than 5 per cent. 

That aortitis and aneurism are frequently caused by syphilis 
is recognized, but hypertension and cardiac disease are more fre- 
quently caused by syphilis than has been noted. Also, heredi- 
tary syphilis is not infrequent, and may occur in families where 
it is least suspected. 

Syphilis of the nervous system, with its many manifesta- 
tions, is now generally recognized, and the disturbance may be 
insomnia, headache, epilepsy, paresis, locomotor ataxia, gum- 
mata of the brain, or insanity. 

To insure the early diagnosis and a consequent successful 
treatment, every suspicious sore should be studied microscopic- 
ally for spirochetes, and if the result is negative, the nearest 
lymphatic glands should be watched for several weeks for signs 
of infection. In suspicious cases where spirochetes are not 
found, the Wassermann test should be made in four weeks from 
the time of the suspicious sore, and again in two or three months. 
This test is positive in practically all cases of active syphilis, 
and if present shows that whatever else the patient has, he prob- 
ably also has syphilis. If the test is negative, he may still have 
syphilis, and later in the disease when the blood is negative to 
this test, the spinal fluid may be positive. This is especially 
true if there are symptoms of nervous syphilis. If both tests 
are negative, he may still have syphilis, and the tests may be- 
come positive later under mercurial treatment. 

The Wassermann test may not only vary greatly in intensity 
from time to time, but it may be absent during treatment or 
without treatment. Also it seems to be an unfortunate fact 
that reports from even the best of laboratories may not always 
be the same with the same sample of blood. Hence, several 
examinations should be made before a result is declared positive, 
provided that the clinical symptoms and signs are not present. 

The luetin skin test, if positive, is indicative of syphilis 
and especially is valuable in latent, tertiary and hereditary 
syphilis, provided the patient has not taken iodine in any 
form just before the test is made. 



TREATMENT OF SYPHILIS 345 

Treatment. — As soon as syphilis is positively diagnosed, 
arsphenamine should be given intravenously, and the adminis- 
tration of mercury should begin. Some specialists in the 
treatment of syphilis believe that mercury should not be given 
until after the arsenic treatment is over, believing that the 
fight against the germ is more effective by this divided treat- 
ment. Also mercury may slow the excretion of arsenic and 
hence cause poisoning. The intensive treatment cannot be 
better outlined than by quoting Fordyce 1 , who advises that 
five or six intravenous injections, of arsphenamine should be 
given at intervals of about one week. Coincidently, he advises 
"that injections of mercury be given intramuscularly, every 
other day, if it is a soluble form of mercury, or once a week, if 
it is an insoluble form." He gives arsphenamine (salvarsan) 
in doses of 0.30 to 0.50 Gm. for men and 0.25 to 0.40 Gm. for 
women. If he uses a soluble form of mercury for these injec- 
tions, he prefers the bichloride, and gives twenty to thirty 
injections, either daily or every other day. If he uses the 
insoluble form of mercury he prefers the grey oil, "(in the form 
of mercurial cream) of which 5 minims represent 1 grain, in a 
series of 10 to 12 injections, or salicylate of mercury (40 per 
cent, suspension) in dosage of 1 to 3 grains, gradually increased, 
ten to twelve injections constituting a course." After this 
course of arsenic and mercury treatment he gives a rest period 
of six weeks, and then repeats the treatment, even if the 
Wassermann test has become negative. 

Many clinicians believe that the old treatment of mercurial 
inunctions is really the best, as injections are very painful 
and are often not well tolerated by the patient. Known quanti- 
ties of mercurial ointment of known strength are now obtain- 
able, and the dosage is thus rendered exact. The mercury 
ointment may be rubbed in daily or every other day, or in 
50 per cent, strength twice a week, as directed, first on one 
part of the body and then on another; the inner sides of the 
arms, thighs, legs, and the abdomen being utilized in turn. 
Some clinicians believe that preparations of calomel can be 
thus used satisfactorily ; others do not believe that it is as satis- 

1 Amer. Journ. Med. Sci., Oct., 1916, p. 469. 



346 THE PRINCIPLES OF THERAPEUTICS 

factory as is the mercurial ointment as it is absorbed more slowly. 
Two to three grams of calomel in one gram of hydrated wool fat 
and two grams of benzoinated lard may be used at each inunction. 

If a syphilitic woman becomes pregnant, she should receive 
active treatment, and such treatment may prevent a mis- 
carriage or premature birth, and her child may not show 
congenital syphilis. 

In nervous syphilis, syphilis of the brain and cord, Swift 
and Ellis first advised injections of salvarsan preparations into 
the spinal canal, and a number of clinicians have developed 
this treatment, either of intraspinal injections of arsphenamine 
or of arsphenaminized serum. It was first thought that 
arsenic given intravenously did not reach the cerebrospinal 
fluid, hence this method of treatment was advised. However, 
it has since been shown that arsenic given intravenously does 
reach the cerebrospinal fluid, hence at least intraspinal treat- 
ment is not always a necessity. However, it seems advisable 
at times in serious cerebral syphilis, or in locomotor ataxia, to 
give arsphenamine both intraspinally and intravenously, and 
at the same time or soon after, mercury should be administered 
by inunctions or otherwise. Kolmer 1 offers a method for 
treating neuro-syphilis by intensive treatment. 

There is also still a belief that iodides are of value in tertiary 
syphilis, and an iodide seems to be good treatment after a 
course of mercury. The best form is sodium iodide, and 
the dose need not be large. The enormous amount of iodides 
given in tertiary syphilis is inexcusable and also useless. Small 
amounts of iodide, not only for the iodine action on the thyroid 
gland, but to aid in the ehmination of stored mercury, which 
may be doing harm in the body, and to thus re-mercurialize the 
fluids of the body, is logical treatment. 

In giving spinal injections, the usual care should be exer- 
cised, namely, that too much fluid be not given, and that too 
great force be not used, and that the patient should remain 
quiet for twenty-four hours to avoid the headache that may 
occur. In locomotor ataxia the injections often cause most 
intense pain of the locomotor ataxic type. 

1 Journal A. M. A., March 20, 1920, p. 794. 



TREATMENT OF SYPHILIS 347 

It is a question for most careful decision when there are symp- 
toms of internal ear disturbance or when there is optic atrophy, 
as to whether arsenic should be administered or not, as arsenic 
has caused serious results in such conditions. On the other 
hand, if the dose is not large, it may do good, and may prevent 
the progress of the optic atrophy. 

If there is acute or subacute nephritis, arsenic in any form 
should not be injected. Also it should be used with great care 
in chronic nephritis, and before it is used, when chronic nephri- 
tis is present, tests of the excretion ability of the kidneys should 
be made. If a syphilitic has chronic nephritis, any treatment 
of the syphilis is a matter of serious consideration, as not only 
arsenic, but mercury and iodides are likely to increase the kidney 
trouble. However, the risk must often be taken, but the deci- 
sion should generally be against the use of arsenic, as the 
largest part of the arsenic injected must be excreted in the urine, 
hence the likelihood of irritation and increased disturbance of 
the kidneys. Also the excretion of arsenic by the kidneys is 
very slow; it may not be all excreted until two or three weeks. 

The arsphenamine treatment may certainly stop the progress 
of locomotor ataxia, and may cause considerable improvement 
of the condition and may even restore the muscular power of a 
bladder paralyzed by this disease. 

The treatment of paresis by intraspinal injections has not 
been very successful, but the statistics are not quite sufficient to 
advise against its use. 

In every case of epilepsy, whether some other tangible cause 
is present or not, the Wassermann test should be made, as 
hereditary syphilis is not an infrequent cause of this serious 
condition. 

Arsphenamine (Salvarsan). — Arsphenamine is an American 
preparation of arsenic for the treatment of syphilis, and occurs 
as a yellowish crystalline powder, readily soluble in water, and 
in watery solutions gives an acid reaction. This drug is offered 
in sterile ampules ready for solution in distilled water, which 
solution is made alkaline by adding a sufficient amount of a 
solution of caustic soda. The exact method of preparing the 
solution, its proper temperature, and the rapidity of the flow for 



348 THE PRINCIPLES OF THERAPEUTICS 

intravenous injections is stated on the package. Such contents 
of the steriletubes as are not used after the ampule is broken 
should be thrown away, as the substance disintegrates. 

Directions also come with each package to show how arsphena- 
mine or neoarsphenamine may be prepared for administration 
intraspinally. It has been considered best to give arsphena- 
minized serum intraspinally. This is prepared from the blood 
of the patient as follows: the arsphenamine is given as usual, 
intravenously; an hour later 40 mils of the blood is withdrawn 
from a vein; this blood is allowed to clot and is placed on ice for 
twenty-four hours; the serum exuded from the clot is then cen- 
trifuged, and 12 mils of this upper centrifuged serum is added 
to 18 mils of sterile physiologic salt solution; this diluted serum 
is then heated to body temperature, and, after an equal amount 
of spinal fluid is withdrawn, is injected intraspinally ; the patient 
is then placed in the Trendelenberg position, to allow the fluid 
to gravitate toward the brain. 

It may later be found that sufficient arsenic reaches the men- 
inges from intravenous injections to preclude the necessity for 
direct spinal treatment. 

Neoarsphenamine (also termed sodium arsphenamine) con- 
tains sodium and is weaker in arsenic content than is arsphena- 
mine, three parts of neoarsphenamine being equal to two parts 
of arsphenamine. Therefore, the dose may be larger. Al- 
though this preparation is preferred by some specialists, prob- 
ably arsphenamine, which is a little more difficult to prepare, 
is the better treatment. Neoarsphenamine must not be 
warmed, as heat causes changes in its chemical constitution. 

Sometimes unpleasant reaction takes place from these arsenic 
injections, such as a temperature of ioo° or 101 F., vomiting, 
diarrhea, dizziness, headache, edema of the face, cyanosis, 
and circulatory depression. Any one or several of these symp- 
toms may occur and last for twenty-four hours. Occasionally 
there has been irritation of the auditory nerve and of the optic 
nerve, and sometimes a serious neuritis has developed. Not 
infrequently albumin is found in the urine, and from intensive 
treatment with arsphenamine chronic arsenic poisoning may 
occur. It has been suggested that, if an intramuscular injec- 



TREATMENT OF SYPHILIS 349 

tion of i to 1,000 epinephrine solution be given about ten 
minutes before the injection of arsphenamine, these unpleasant 
symptoms are not so likely to occur. If they do occur injec- 
tions of tyramine or epinephrine are indicated, as the suprarenal 
glands seem to be inhibited. 

Serious, even fatal poisoning (unless the dose is small) may 
occur from both neoarsphenamine and arsphenamine injections, 
such as toxic jaundice, exfoliative dermatitis, thrombosis, phle- 
bitis, and gangrene. 

Kolmer and Yagle 1 have come to the following conclusions 
concerning arsphenamine and neoarsphenamine: 

1 . All solutions of arsphenamine are hemolytic, but they are 
from three to ten times less hemolytic in isotonic saline solution 
than in solutions in water. 

2. The hemolytic action of arsphenamine is increased un- 
avoidably by the addition of sodium hydroxide for neutralization, 
and an excess of the alkali increases the hemolytic activity. 
Also, concentrated solutions of arsphenamine, either in water 
or isotonic saline are more hemolytic than dilute solutions. 

3. Neoarsphenamine is not hemolytic, though very dilute 
solutions are, owing to hypotonicity of the solution. Concen- 
trated solutions, as 0.9 Gm. in 30 mils or less of water are not 
hemolytic. 

4. "To avoid hemolysis in the administration of dilute solu- 
tions of neoarsphenamine sterile physiologic sodium chloride 
solution prepared of freshly distilled water should be used; when 
the concentrated solutions are administered (each 0.1 Gm. 
dissolved in 3 mils or less) sterile distilled water may be em- 
ployed. " They also caution that injections of arsphenamine 
and neoarsphenamine solutions should be slow, to allow a grad- 
ual mixing with the blood. Schamberg, Kolmer, and Raiziss 2 
find that neoarsphenamine is safer than arsphenamine. 

As stated, neoarsphenamine is more easily prepared for 
administration. On the other hand, when arsphenamine is 
very carefully prepared, not given too concentrated, and prop- 
erly alkalinized (not too strongly alkaline) disagreeable after 

1 Journal A. M. A., March 6, 1920, p. 643. 

2 Amer. Journ. Med. Sci., July, 1920, p. 25; and Aug., 1920, p. 188. 



350 THE PRINCIPLES OF THERAPEUTICS 

symptoms will not often occur. In other words, it is a case for 
the specialist. Only one who has become expert and has the 
proper facilities for properly preparing and properly administer- 
ing arsphenamine should perform this operation. Also, it 
should be considered an operation, and the patient should re- 
main quiet for at least twelve or fifteen hours after the injection. 
It seems inexcusable to give such a treatment in the physician 's 
office and then send the patient home within an hour or so. 

It does not seem advisable to administer mercurialized serum 
intraspinally, as has been suggested, or perhaps intravenously, 
but intramuscular injections of mercurialized serum may be an 
improvement on injections of stronger preparations of mercury. 

Bailey and MacKay 1 have studied the disturbances caused by 
injections of arsenic in the treatment of syphilis and especially 
the disturbances of the liver. They think that an increase of 
cholesterol in the blood is an early prominent sign of imminent 
liver congestion and toxic jaundice, and suggest frequent exami- 
nation of the blood for this substance during the intensive treat- 
ment of syphilis as a warning against too frequent injections of 
arsenic. They also urge the restriction of exercise during the 
active treatment, and advise a diet rich in carbohydrate and low 
in fat and protein before, during, and immediately succeeding 
the arsenic treatment. The amount of protein later allowed 
and the return to exercise and work should depend upon the 
amount of urea in the blood. 

These recommendations are timely, as this active, perhaps 
necessary, more or less dangerous treatment of syphilis is often 
recklessly carried out. The watchward should be skilled treat- 
ment, caution, rest, and frequent study of the exact condition 
of the patient, best carried out at a hospital. 

If for any reason it is deemed unwise to administer ars- 
phenamine intravenously, it may be given by enteroclysis with 
reported good results. The preparation of the patient and the 
technique have been recently described by Wright. 2 

Intramuscular Injections of Mercury. — Sterile ampules may 
be obtained of several forms of insoluble mercury for intra- 

1 Arch. Int. Med., June, 1920, p. 628. 

2 New York Med. Journ., Aug. 28, 1920, p. 275. 



TREATMENT OF SYPHILIS 351 

muscular injections. Consequently, it would seem as though 
the doubtful preparation of such solutions extemporaneously 
is not excusable. 

Sterile ampules may be obtained of salicylate of mercury, 
each containing 0.13 Gm. (2 grains), with quinine and urea 
hydrochloride ^ per cent, suspended in oil. The dose is J12 to 1 
ampule, the quinine and urea hydrochloride acting as an anes- 
thetic. The ampules should be warmed before the solution is 
drawn into the syringe for injection. 

Besides the salicylate, ampules of mercury succinimide may 
be obtained. Each ampule contains 1 mil of the sterilized 
aqueous solution of mercury succinimide 0.01 Gm. (3^3 grain). 
The dose is one to two ampules. 

These injections are usually made into the gluteal muscles, 
not so low down that the patient cannot sit, also the region of 
the sciatic nerve must be avoided. The two sides of the body 
are used alternately; care should be taken not to puncture 
a vein, therefore the barrel should be detached from the needle 
to see if blood flows. If blood does flow, the needle should 
be withdrawn and another puncture made. There should be 
no massage of the injected tissues. 

The soluble salts of mercury should be used by preference 
when rapid mercurial action is desired, and in the beginning of 
the treatment. Later the less soluble salts may be used. The 
injections (salicylate salt best) should not be more fre- 
quent than once a week, as absorption is slow. The dis- 
advantage of this treatment is the pain which is caused, and 
with the soluble salts the pain may begin at once and may 
last several hours. With insoluble preparations the pain may 
not begin until after an hour or two, but may last for 
several days. 

Sometimes hard tumor masses form which absorb very 
slowly, depending upon whether the injection has been made 
close to fascia rather than into the muscle substance. Abscesses 
may rarely occur, and embolism has occurred. 

The same general hygienic care of the mouth and of the 
bowels, a nutritious diet, and hot water bathing should be 
ordered when mercury is given by injection or by inunction, 



352 THE PRINCIPLES OF THERAPEUTICS 

as when it is given by the mouth. It seems to be doubtful 
if mercury reaches the meninges of the brain and cord, hence 
the advisability of both the arsphenamine and the mercury 
treatment for syphilis of the central nervous system. 

THE SPECIFIC TREATMENT OF TETANY 

Tetany has been shown to be due to disturbance of the 
parathyroid glands, and when the parathyroids are removed 
the animal develops tetany. This tetany is stopped by para- 
thyroid gland extracts, and by the administration of calcium, 
best associated with the administration of cod liver oil. 

Calcium. — Calcii Chloridum. — Calcium chloride occurs as 
a white, very deliquescent salt, has a sharp, saline taste, is 
irritant, and is soluble in water. This disagreeable preparation 
has no advantage over more pleasant salts of calcium. The 
dose is 0.30 Gm. (5 grains), generally administered three 
times a day. It must be given in solution and with some 
thick syrup, else vomiting will be caused. 

Calcii Lactas. — Calcium lactate occurs as an odorless, taste- 
less powder, not very soluble in water, is only slightly irritant, 
and does not disturb the stomach when taken well diluted or 
after meals. The dose is 0.30 Gm. (5 grains), best administered 
in powder and taken with milk after meals. 

Calcii Glycerophosphas. — Calcium glycerophosphate occurs 
as a fine, white powder, is almost tasteless, is practically 
insoluble in water, and is best administered in powder or 
capsules. The average dose is 0.50 Gm. (7^2 grains) three 
times a day, after meals. This is a pleasant and efficient 
method of administering calcium. 

Liquor Calcis (Solution of Calcium Hydroxide). — Lime 
water is a bland, non-irritant solution, mildly antacid, and 
slightly constipating. It is absolutely tasteless, if taken in 
milk. It is often added to the milk of infants, as the alkali 
tends to prevent the formation of large curds in the stomach. 
The dose of lime water as generally administered is too small, 
and 2 or 3 teaspoonfuls should be added to each milk feeding, 
depending upon the age of the child. 

Lime water is combined with linseed oil, equal parts, to form 



TREATMENT OF TETANY 353 

the official Linimentum Calcis (Carron Oil), which is a soothing 
alkaline preparation largely used for burns. 

Calcii Carbonas Prcecipitatus (Precipitated Chalk) is some- 
times used as an antacid. 

Creta Prceparata (Prepared Chalk) is administered internally, 
mostly in the form of the official Mistura Creta (Chalk Mixture), 
which is given, in a dose of 15 mils (about 4 fluidrams), for 
diarrhea in infants. Precipitated chalk and prepared chalk are 
used mostly externally, and the latter is the main ingredient of 
many tooth powders. 

Syrupus Calcii Lactophosphatis is used for marasmic children 
in the dose of 10 mils (2^ fluidrachms) ; but good food and plenty 
of milk makes this preparation rarely needed. One quart of 
milk represents about 2 Gm. of calcium, and 1 Gm. (15 grains) 
of calcium is about sufficient for normal metabolism for twenty- 
four hours. 

Holt, Courtney and Fales 1 have determined that an excessive 
calcium intake dose not apparently increase the calcium absorp- 
tion, the excess being excreted. They also determined that the 
calcium absorption by rachitic infants was much lower than by 
healthy infants, and that the administration of cod liver oil 
increased the absorption of calcium, unless diarrhea was present. 
This means, as has long been clinically known, that cod liver oil 
is a valuable treatment for marasmic and rachitic children, 
combined, of course, with proper food and plenty of milk. 

Action. — The importance of -calcium to the economy (it rep- 
resents about one-fiftieth of the body weight) is being more and 
more recognized. A child cannot grow properly when deprived 
of calcium, neither can an adult be normal when deprived of it. 
Also, anything that causes a great loss of calcium to the body 
causes symptoms more or less serious, due to such loss. 

The seriousness of acidosis and its frequency as a terminal 
condition in many chronic and acute diseases has only recently 
been known. Even a mild form of acidosis may cause vomiting, 
diarrhea, and cerebral irritation, and serious acidosis will cause 
coma, as seen in diabetes. Prolonged privation of carbohy- 
drates and starvation will cause acidosis and the symptoms 

1 Amer. Journ. Dis. Child., Feb., 1920, p. 97. 
23 



354 THE PRINCIPLES OF THERAPEUTICS 

above described. There may also be an increased temperature, 
rapid pulse, and tetany. 

A shortage of calcium seems to cause disturbance of the para- 
thyroid glands, and nervous irritability, sleeplessness, spasmo- 
philia, or convulsions may occur depending upon the amount of 
parathyroid disturbance present. Privation of carbohydrate 
foods and perhaps especially of calcium may be a cause of 
meningism in typhoid fever and other serious infections. 

The part played by the parathyroids in epilepsy is not known, 
but it is a fact that the less meat and the more starch in the food, 
the less frequent are the convulsions. The administration of 
calcium as well as other alkalies frequently prevents the necessity 
for large doses of bromides in epilepsy; a small dose of a bromide 
combined with alkaline treatment is often satisfactory. 

The relation of the pituitary secretion to the parathyroids 
is not known, but in hypersecretion of the anterior pituitary an 
extra amount of bone is produced. This means an extra amount 
of calcium is utilized for bone growth. 

In hyperactivity of the thyroid, whatever other treatment is 
instituted, the administration of calcium always quiets nervous 
irritability, as it seems to soothe the central nervous system. 

The calcium metabolism of the mother is disturbed to her 
disadvantage by too frequent pregnancies, and even in a single 
pregnancy, many times, the mother's teeth become decayed, 
her hair falls out, and her finger nails become brittle, showing 
that she requires more calcium than she is receiving, or at least 
than she is utilizing, extra calcium being required for the growth 
of the child. Too frequent pregnancies exaggerate this condi- 
tion, and lactation will use up the mother's calcium, and she 
requires more, and if her metabolism does not properly utilize 
the calcium that she receives she becomes nervous, irritable, has 
headaches, loses weight as well as her teeth and hair, and may 
have bone softening, as occurs in osteomalacia. 

Whether ovarian disturbance or the extra ovarian activity in 
frequent pregnancies is the cause of osteomalacia, or whether 
the too frequent formation of the corpora lutea of pregnancy is 
the cause, osteomalacia certainly occurs generally only after such 
ovarian or corpora lutea hyperactivity. A patient with osteo- 



TREATMENT OF TETANY 355 

malacia requires large amounts of lime. Sometimes removal of 
one or one and a half ovaries has been curative. 

On the other hand, normal activity of the ovaries and of the 
testicles may have something to do with normal calcium elimina- 
tion, as at the time of life when the activity of these glands is 
diminished, hardening of arteries and other signs of calcifi- 
cation often occur. 

Givens has shown that we cannot by food increase the calcium 
of the body without also increasing magnesium, and there is 
generally more calcium than magnesium excreted in the urine. 
Both can be increased by the ingestion of milk. Givens rinds 
that calcium lactate always increases the urinary calcium output, 
but relatively not more than when milk is given. He also found 
that the ingestion of dilute hydrochloric acid does not much 
affect the calcium and magnesium metabolism. 

It seems to be a clinical fact that a hyper-acid individual is 
more likely to have neuralgias and neuritis than when his diet 
is changed to one of more carbohydrate and less meat, and 
when he is given alkalies; and the best alkali for nervous irri- 
tability of all kinds is calcium. If milk is well tolerated, it is 
one of the best means of administering more calcium, and the 
best medicinal way is to give calcium glycerophosphate. 

Children seem to store calcium more readily than adults, 
probably because physiologically they need more calcium, not 
only for their normal metabolism, but also for their bone 
growth. 

Only a small amount of calcium intake is actually absorbed, 
a large portion forming salts and passing off in the stools, and 
even a portion of the calcium that is absorbed is excreted into 
the intestines through the epithelium. The calcium excreted 
in the urine occurs mostly as a phosphate. 

It seems to be a clinical fact that patients with active tuber- 
culosis excrete an abnormal amount of calcium; they lose cal- 
cium which they need for the cure of the tuberculosis. There- 
fore milk or extra amounts of calcium should be fed these 
patients, and sometimes cod liver oil. 

While it is unusual for ordinary diets to cause lime priva- 
tion, a meat and bread diet will do this. Also, lime may be 



356 THE PRINCIPLES OF THERAPEUTICS 

taken, yet for some chemical reason may be lost to the body; it 
may not be normally absorbed. On the other hand, as pre- 
viously stated, calcium may be excreted in an abnormally large 
amount, and such patients will show symptoms of lime starva- 
tion. This condition of non-utilization of calcium is similar to 
the condition of chlorosis where iron may be taken in normal 
amount in the diet by a girl, and yet she becomes chlorotic. 

Lime is essential for the normal clotting of blood, although 
it does not enter into the formation of fibrin. Although cal- 
cium will not often stop the bleeding of hemophiliacs, and may 
not stop a tendency to hemorrhages, still it should be admin- 
istered in all individuals who are bleeding, from the bleeding 
gums of scorbutus to the oozing hemoptysis of tuberculosis, 
and when there is actual hemorrhage. Surgeons who must 
operate upon jaundiced patients believe that by a previous 
feeding of calcium they lessen the tendency to hemorrhage, 
and the danger of hemorrhage is always present when there 
are bile salts in the blood. 

It would seem a biologic necessity to see that a pregnant 
woman receives more calcium than she previously has been tak- 
ing, not only to supply the fetus with its needs, but to cause her 
not to be depleted of the calcium that she needs. 

In rickets and in all softening of bone, and possibly after 
fractures, an extra amount of calcium is needed, and as above 
stated, in cachectic children calcium and cod liver oil are 
valuable added treatments. 

While calcium phosphate may be logically the salt that seems 
advisable for bone growth, administration of this salt is not 
more effective, perhaps not as effective, as the administration 
of a preparation like calcium glycerophosphate; but in whatever 
form the calcium is administered it must be broken down and 
rebuilt for the needs of the body and tissues. All hypophos- 
phite combinations, whether with or without calcium, are use- 
less medicaments, and there is no justification for the faith in the 
value of hypophosphites. The doubt of their value is also 
shown by all proprietary medicine firms, who offer hypophos- 
phite preparations, almost invariably adding quinine, iron, 
strychnine, or something else to their hypophosphite mixtures. 



CINCHONA 357 

CINCHONA 

Cinchona — Calisaya; Calls ay a Bark; Yellow Peruvian Bark.— 
Cinchona originally came from Peru (hence called Peruvian 
Bark), and became known as a cure for malarial infections in 
1638, and from this date there has never been found a better 
cure for malarial fevers. It was named Cinchona on account of 
its having cured the Countess of Chinchon, of Spain. At the 
present time cinchona is mostly obtained from India and Java. 
Cinchona is not used as such. The only preparation of 
value is Tinctura Cinchona, which represents 20 per cent, of 
the drug, and the dose of which is a teaspoonful. This prepara- 
tion is as valuable as a bitter tonic as is the tincture made 
from the red cinchona, namely, Tinctura Cinchona Composita 
(Huxham's Tincture). This compound tincture of cinchona 
contains serpentaria, and there is no necessity for officializing 
or using the plant serpentaria. If it is desired, syrup of orange 
may be added to the Tinctura Cinchona, which makes a 
pleasant, bitter preparation. 

Cinchona Rubra (Red Cinchona, Red Peruvian Bark) is not 
used as such. 

The official alkaloids of cinchona are quinine, cinchonidine, 
and cinchonine. There is no necessity for officializing the last. 

CinchonidincB Sulphas occurs as white silky needles or 
prisms, has a very bitter taste, is slightly soluble in water and 
the average dose is 0.15 Gm. (2^ grains); however, the dose 
depends upon the object for which it is used. 

Quinine. — Administration. — This alkaloid is used mostly in 
the form of one of its salts. 

Quinince Bisulphas (Quinine Bisulphate) occurs as colorless 
or whitish crystals, has a very bitter taste and is soluble in 
water. The dose is 0.10 Gm. (i^i grains). 

Quinince Dihydrochloridum (Quinine Dihydrochloride) occurs 
as a white powder, has a very bitter taste, is very soluble in 
water, and the dose is 0.10 Gm. (i}i grains). 

Quinince et Urece Hydrochloridum (Quinine and Urea Hydro- 
chloride) is a compound of the hydrochlorides of quinine and 
urea. It occurs as colorless prisms or as a white granular 
powder, has a very bitter taste, and is very soluble in water. 



358 THE PRINCIPLES OF THERAPEUTICS 

This drug is used mostly hypodermatically, and the dose, once 
a day, is i Gm. (15 grains). It is also (now rarely) used as a 
local anesthetic in about 15 per cent, solutions for mucous 
membranes, and in 0.5 to 1 per cent, solutions for injections. 

QuinincB Eydrobromidum (Quinine Hydrobromide) occurs 
as white needles, has a very bitter taste, is not very soluble in 
water, and the dose is 0.10 Gm. (1}^ grains). 

Quinince Hydrochloridum (Quinine Hydrochloride) occurs as 
white needles, has a very bitter taste, is soluble in water, and 
the dose is 0.10 Gm. (ij£ grains). 

QuinincB Sulphas (Quinine Sulphate) occurs as white crystals, 
has a very bitter taste, is practically insoluble in water, and 
the dose is 0.10 Gm. (1^ grains). This is the preparation of 
quinine that is the most used. The anti-malarial doses of all 
quinine salts are very much larger than the tonic doses. 

The salicylate and the tannate of quinine, though official, 
are not important. 

When soluble preparations of quinine are desired for internal 
administration, the bisulphate or the dihydrochloride are the 
preparations to use. The hydrobromide is supposed to have a 
slight sedative effect and not to be quite as excitant to the 
brain as are the other quinines. As the most insoluble prepara- 
tion, namely, the sulphate, causes quinine activity almost as 
rapidly as the more soluble forms, this is the preparation that 
is most used. It may be administered in flexible capsules 
(which may not always dissolve) or in freshly made gelatin 
capsules. If rapid action is desired, a capsule may be uncapped 
before swallowing. There is absolutely no excuse for ordering 
the sulphate of quinine, and adding acid to dissolve it, in a 
liquid preparation. If a soluble preparation is required, as 
just stated, the dihydrochloride or the bisulphate should be 
used. When quinine is administered to a child that cannot 
swallow a capsule or a pill, several methods of administering the 
alkaloid may be tried. A freshly made pill may be crumbled 
and placed in a teaspoonful of jam or thick chocolate or other 
soft food that the child can take. Or a solution of the bisul- 
phate or the dihydrochloride in water may be administered, in 
the dose desired, in a cup of cocoa or chocolate. The so-called 
tasteless quinines are mostly tannates, and are for that reason 



QUININE 359 

very insoluble in the alimentary canal, and but little quinine 
is absorbed. 

As a tonic quinine may be given as the tincture of cinchona 
in teaspoonful doses before meals; the bitter often acts as an 
appetizer. Or, if quinine is taken in a capsule or pill after 
meals, enough of the quinine is excreted in the saliva to cause 
a bitterish taste before the next meal, and for this reason 
quinine thus administered acts as a stomachic. 

Action. — Quinine is a protoplasmic poison, has antiseptic 
and germicidal qualities, and, when in solution, acts more or 
less as a preservative and may destroy many bacteria. It 
specifically destroys the Plasmodium malarice, acting more 
efficiently on the. full grown parasite than when it is in the 
sporule stage. 

Locally on the unbroken skin quinine has no action; on mu- 
cous membranes it causes a slight irritation ; and in the stomach 
it is distinctly stimulating to the secretions. The acid of the 
gastric juice renders the sulphate of quinine soluble and causes 
it to be more or less rapidly absorbed. Probably the quinine 
that is not absorbed in the stomach, and reaches the intestines 
and therefore alkaline media, is not absorbed at all, and passes 
out of the body with the feces. 

Except in small doses, quinine, even in capsules, should not 
be taken before meals or on an empty stomach, but always 
after meals; or, if a large dose must be given at some other 
time, it may be administered with milk, or with malted milk, or 
with some other simple food, else irritation and even vomiting 
may be caused. Sometimes constipation is caused by quinine, 
possibly on account of its inhibitory action on the normal bacteria 
of the intestines. 

The larger part of an ordinary dose is generally absorbed in 
two or three hours, and in the blood it quickly inhibits the 
activity of, and destroys, malarial parasites. It may also more 
or less inhibit ameboid movement of the polymorph leucocytes. 
For this reason it has been thought that it is not well to give 
quinine in septic diseases, as it may interfere with normal phago- 
cytosis, and there is no question but that too much quinine has 
been given in all kinds of disease. 



360 THE PRINCIPLES OF THERAPEUTICS 

Quinine in small doses is more or less stimulant to the heart, 
especially noticeable in those who frequently take quinine and 
rely on it for stimulation. In large doses it is depressant to the 
heart and may considerably lower the blood-pressure. Full 
doses of quinine dilate the blood-vessels, especially of the face 
and head, and may cause considerable fullness of the head and 
ringing in the ears, perhaps suffusion of the eyes, and may cause 
headache from the increased cerebral circulation. With this 
effect on the head there may be dizziness, in part due to in- 
creased pressure in the head and in part due to disturbance in 
the middle ear, and large doses cause ringing, buzzing, and even 
roaring sounds in the ears. During this action there may be 
some deafness, especially in individuals who are already partial- 
ly deaf. If large doses are prolonged, rarely, more or less 
permanent deafness may be caused. Very rarely a single large 
dose has caused deafness, but probably in these instances some 
disease of the middle or internal ear was already present. 
Occasionally there has been temporary blindness caused by the 
drug, but this is very rare. The pupils may dilate, and there 
may be imperfect accommodation. Sometimes delirium is 
caused by quinine. 

Large doses in feverish processes will reduce temperature, 
but such an effect is combined with so much disagreeable action 
that there is no excuse for using quinine as an antipyretic, 
expect in the specific case of a malarial fever. Some of this 
diminution of fever is probably due to action on the heat pro- 
ducing centers in the brain, and also perhaps due to the de- 
creased general metabolism which large doses of quinine causes. 
It seems probable that small doses of quinine are more or less 
stimulant, and large doses of quinine are always more or less 
depressant to nitrogen metabolism. 

Quinine is probably destroyed by many tissues of the body, 
perhaps largely by the liver. It is excreted mostly through the 
kidneys, and may be found in the blood and in the urine an 
hour after it has been administered, but the whole dose is excreted 
slowly, and, if several doses have been taken, it may take several 
days before it is all excreted. Considerable quinine may be 
found in the feces, some passing through the intestine unab- 



QUININE 361 

sorbed, and perhaps some is excreted with the bile, after passing 
through the liver. Quinine may also be found in the perspira- 
tion, in the saliva, and in the milk of nursing women. 

Quinine has an oxytocic effect, causing contraction of the 
uterus during and after parturition. It may also cause con- 
traction of the uterus when abortion is about to take place. It 
is probably very rare that quinine, in any dose, will produce an 
abortion unless muscular contractions of the uterus have al- 
ready begun. The coincidence of miscarriage occurring after 
large doses of quinine have been administered has been probably 
inexcusably laid to the quinine. A severe chill and fever from 
malarial poisoning can alone produce an abortion. 

Quinine is not now often administered to women to prevent 
or stop the after-pains; if a uterine contractor is needed, pitui- 
tary extract is more popular. 

Over-action. — Unexpected action from quinine is not infre- 
quent, and not a few individuals have an idiosyncrasy against 
it. The common effects of a large dose are what has been 
termed in totality " cinchonism, " namely, ringing in the ears, a 
full-headed feeling, flushed face, sometimes a rapid heart, some- 
times dizziness, and sometimes disturbed vision. Not infre- 
quently quinine will cause an urticarial eruption on the skin. 
This condition of cinchonism may generally be prevented by the 
coincident administration of a bromide. 

Unexpected symptoms, or symptoms of idiosyncrasy, are 
great cerebral excitement even delirium, and more frequently 
swellings of the face, tongue, and other parts of the body, and a 
general anaphylactic disturbance. Individuals who have this 
idiosyncrasy may have serious symptoms from a very small 
dose, even 0.05 or 0.10 gram of any alkaloid of cinchona, and 
perhaps more frequently from quinine than from cinchonidine. 

Many of these patients who have this idiosyncrasy against 
the first dose of quinine are then not over-susceptible to ordinary 
dosage during that particular illness, but in a subsequent illness 
may be again poisoned by the drug. On the other hand, some 
few individuals should never be given a second dose of quinine. 

O'Malley and Richey 1 have found that patients showing 

1 Archiv. Internal Med., Oct., 1919, p. 378. 



362 THE PRINCIPLES OF THERAPEUTICS 

idiosyncrasy to quinine will give a positive reaction to the skin 
antigen test. They found in some instances that they could 
desensitize a patient by giving a very small dose, as 0.005 Gm. 
of quinine with 0.50 Gm. of sodium bicarbonate, and then 
in an hour and a half the patient could take 0.10 Gm. of the 
bisulphate of quinine with 0.50 Gm. of sodium bicarbonate in a 
cachet without symptoms. Each day they desensitized with 
the same dose and gradually increased the therapeutic dose of 
quinine. 

Toxic Action. — The fatal dose of quinine is excessively large, 
and death from even enormous doses is probably almost 
unknown. At the same time, serious cardiac depression may 
be caused, as well as there may be serious effects on the eyes 
and ears from excessively large doses. However, a patient 
with a severe malarial fever will withstand enormous doses of 
quinine that would be poisonous to individuals who do not 
have this infection. 

Treatment 0] Poisoning. — This depends on the symptoms. If 
the symptoms are cerebral, bromides in large doses, with ergot 
intramuscularly is the treatment. If there is collapse, the 
patient should be kept warm and given suprarenal extract and 
perhaps atropine. Sodium bicarbonate in large doses will prob- 
ably always be of benefit in quinine poisoning. Also plenty 
of water should be administered. 

THE SPECIFIC TREATMENT OF MALARIAL FEVERS 

For very many years cinchona and its alkaloid quinine have 
been used for all malarial fevers, but it was not until the 
Plasmodium malarice was discovered that it was known exactly 
how quinine acted. Quinine is especially efficient in the tertiary 
and quotidian types of malarial fever, less rapidly efficient in 
the quartan and estivo-autumnal types. 

A form of malarial fever is termed "pernicious," in which the 
chill is excessive, the prostration profound, and the patient 
may die in coma, or the fever may be so excessive as to be itself 
dangerous. In this form, quinine if given soon enough and in 
large enough doses is also curative. In this type, namely, per- 
nicious malarial fever, quinine is often given intravenously or 



TREATMENT OF MALARIAL FEVERS $6$ 

subcutaneously. Although in tropical climates the intravenous 
method has seemed to save lives that otherwise would not have 
been saved, still large doses of quinine intravenously are danger- 
ous, especially if the blood-pressure is low. Also these injections 
should be given slowly. 

Stephens 1 found that the administration of 30 grains of 
quinine by the mouth on two consecutive days, once a week for 
a period of five weeks, would eradicate malarial germs. He does 
not find that the combination with arsenic is any more efficient 
than when quinine is given alone. 

Two principal methods of administering quinine have been 
used. One method is to give a large dose four or five hours be- 
fore the expected chill. The other method is to give a small 
dose repeatedly, every hour or two. The success of the treat- 
ment perhaps largely depends on the region in which the patient 
who has the malarial poisoning lives. Quite generally in the 
temperate climate, if the dose of quinine sulphate is given in 
soluble capsules four hours before the expected chill, when the 
type is learned and it is known when the chill will occur, it is 
very successful in preventing or at least greatly modifying the 
next paroxysm. Namely, if the chill is expected at 10 A. M., 
the patient is given 0.60 Gm. (10 grains) of quinine at six o'clock 
in the morning with some coffee and toast, or with some milk. 
He then goes to bed, and receives no more quinine until the 
evening of that day, at which time he should receive 0.30 Gm. 
(5 grains) after the evening meal, and the same dose three times 
a day, after meals, on the following day. At six o'clock on the 
second morning he should take another 10-grain dose. Ordi- 
narily the patient will have no more chills. If he omits the 
chill on the second period, he need take no more quinine on that 
day. On the following day he may take 5 grains twice a day 
for several days, then 3 grains three times a day for several more 
days, and finally 2 grains three times a day for several weeks. 

To prevent cinchonism from the larger doses a sodium bro- 
mide mixture should be prescribed, each 5 mils representing 1 
Gm. of the bromide, and the patient may be given 0.20 Gm. (3 
grains) of the bromide for every 0.06 Gm. (1 grain) of the qui- 

1 Annals of Tropical Medicine and Parasitology, Liverpool, May 12, 1919, p. 69. 



364 THE PRINCIPLES OF THERAPEUTICS 

nine. In other words, when he takes 0.60 Gm. (10 grains) of 
quinine he takes 2 Gm. (30 grains), 2 teaspoonfuls, of the bro- 
mide; and when he takes the 0.30 Gm. (5 grains) of quinine he 
takes 1 teaspoonful, representing 1 Gm. (15 grains) of the bro- 
mide, and cinchonism will ordinarily not occur. If a patient 
is weak and it seeems inadvisable to give him bromide, ergot 
may be given an hour or so before the dose of quinine, and cin- 
chonism may thus be prevented. 

The size of the dose of quinine of course depends upon the age 
of the patient, the intensity of the chill, and the severity of the 
illness. 

As above stated, quinine will probably not kill the malarial 
Plasmodium when in spore form. Therefore, quinine must be 
more or less in evidence in the blood awaiting the development of 
the spores into mature plasmodia, when the quinine is actively 
effective. Some clinicians believe that the patient should 
receive a dose of quinine in the middle of the night, as not 
sufficient quinine will remain in the blood to kill these maturing 
spores. But when it is recognized how slowly quinine is ex- 
creted, at least after several doses have been taken; also when it 
is remembered how long it takes the spore to develop, it would 
seem unnecessary to give the quinine at night, unless there was 
a double infection and the type was quotidian. 

It is always well to give a good purgative, either calomel or 
castor oil, before beginning the quinine treatment, if one can wait 
for the action of the purgative, as it is best that the intestines 
should be clean and that the liver should be relieved of impaired 
bile and should be ready for its detoxicating action both on the 
quinine and on the results of the infection. The diet should 
also be low on the first day or two of treatment, but as soon as 
the patient is without fever he certainly should receive good 
nourishment, but not much food for five or six hours, at least, 
before the expected chill. Large amounts of water should 
always be given during the treatment. 

When it is deemed advisable to give quinine frequently rather 
than in the above infrequent doses, the amount should generally 
be either 0.10 Gm. (ij^ grains) every two hours, or 0.15 Gm. 
(2^ grains) every three hours, in capsule, and this dose should be 



TREATMENT OF MALARIAL FEVERS 365 

continued night and day for two days, and then a little less 
frequently for a few more days. 

At times it seems well to stop the quinine for three or four 
days and give iron, which seems to help drive the plasmodia 
from the parts of the body in which they hibernate (perhaps 
mostly in the spleen), allow them to mature, and then give a 
day or two of intensive treatment with quinine, and then con- 
tinue the small tonic dose for a long period. Often it is best to 
give arsenic, either alone or coincidently with quinine, o.ooi or 
0.002 Gm. (3^30 or Mo grain) of the trioxide, three times a day, 
perhaps well combined in a dry capsule with quinine o.io Gm. 
and reduced iron 0.05 Gm. This capsule may be given for some 
time, perhaps omitting it during the menstrual period of women, 
provided that there are no active malaria symptoms. 

It has lately been shown, especially in the Southern parts of 
the United States, that the malarial plasmodium is harbored for 
many months in the body unless it is positively driven out. 
Hence intensive treatment of malarial fever is urged, on the 
belief that it requires long treatment with large doses to posi- 
tively detoxicate an individual who has once been infected by 
the malarial plasmodium. 

Mayne and Carter 1 offer the following scheme for the treat- 
ment of a patient who has malarial plasmodia in his blood: give 
40 grains of quinine a day for five days; half this dose for double 
the number of days, namely, 20 grains for ten days; and then the 
same ratio of reduction of the dose and of increase of the days, 
namely, 10 grains for twenty days, and lastly, 5 grains for 
forty days. 

Bass, 2 who has for years carefully investigated the subject 
of the treatment and prevention of malaria, believes that the 
detoxication treatment should be as follows: 10 grains of qui- 
nine sulphate every night before retiring for a period of eight 
weeks. For children the dose should be 3^> a grain before one 
year of age, 1 grain after one year of age, 2 grains after two 
years of. age, 3 grains for the third and fourth years of age, 4 
grains for the fifth, sixth and seventh years of age, 6 grains for 

1 The Journal A. M. A., Oct. 11, 1919, p. 1119. 

2 The Journal A. M. A., April 26, 1919, p. 1218. 



66 THE PRINCIPLES OF THERAPEUTICS 



the eighth, ninth, and tenth years of age, 8 grains for the eleventh 
twelfth, thirteenth and fourteenth years, and 10 grains for all 
over fifteen years of age. 

There probably is no way to eradicate malarial fever except by 
preventing an infected patient from becoming a carrier. During 
the acute infection the room should be screened so that there 
is no possibility of mosquitoes biting him and becoming trans- 
mitters of the disease. Also the patient should be so detoxicated 
that he can never cause a mosquito to become infected, which 
might occur if he is a carrier, though he himself may apparently 
be immune to the disease. 

There seems to be no excuse for administering quinine during 
the chill and subsequent fever. If the patient is seen first dur- 
ing the chill, the sweating stage should be hastened by giving 
him drinks of hot lemonade, and surrounding him with hot 
water bags. If the patient is seen during the intense headache 
and high fever, he should be given a dose of an antipyretic, 
as 0.20 Gm. (3 grains) of acetanilid, with 0.50 Gm. (7^ grains) 
of bicarbonate of sodium, with hot tea or hot lemonade, or, if 
he prefers, lemonade of ordinary temperature, certainly not 
iced. Or he may be given 1 Gm. (15 grains) of antipyrine. As 
soon as the sweating stage develops, he is comfortable, and 
except for preventing his becoming chilled, he should receive 
no treatment, unless it seems advisable to begin the quinine, 
which ordinarily, however, may wait until a few hours later. 

Lately there has been considerable discussion as to the value 
of so-called prophylactic doses of quinine, such doses being 
given to individuals who must go to, or remain in, climates 
where malarial infected mosquitoes are known to be abundant. 
Such treatment, however, has proved not to be very successful,, 
and the only successful prevention is to abolish the mosquito 
in the regions where civilized man must remain. That this can 
be done is shown by the wonderful prophylactic sanitation of the 
Panama Canal region. As just stated, it is still disputed 
whether from 3 to 5 grains of quinine taken daily will prevent 
infection from a bite of an infected mosquito. Cowan and 
Strong 1 have recently stated that some patients, having taken 

1 Quarterly Journ. of Med., Oxford, Oct., 1919, p. 1. 



TREATMENT OF MALARIAL FEVERS 367 

quinine for a long time, really suffer from quinine poisoning, and 
especially is it inadvisable to give very large doses in chronic 
malaria. They would rely on arsenic in chronic malaria. 

This difference of opinion from different parts of the world 
may represent different types of the disease. There is no 
question that we must recognize that the constant taking of a 
protoplasmic poison as is quinine cannot be to the advantage of 
the individual. It is an appetizer and a stimulant, but at the 
same time it may inhibit many cellular and glandular activities. 
It also is a habit-forming drug; the patient soon misses the 
stimulation when the drug is stopped. At times it has been 
noted in tropical regions that if hemoglobinuric fever develops, 
those who have taken considerable quinine previously have the 
disease more severely. We must, however, come to the con- 
clusion that for short periods at least, a prophylactic dose of 3 
to 5 grains of quinine aids in preventing malarial infection. 

The treatment of estivo-autumnal fever combines so much 
more than the administration of quinine that it belongs to a 
book on therapeutics. The relation of hemoglobinuric fever 
to malaria and the treatment with quinine is also too broad 
a subject to here discuss. Suffice it to say that in some cases 
the administration of quinine may increase the danger from 
hemoglobinuria, however, it seems still to be the best treatment 
for this form of fever. The germs of hemoglobinuric fever can 
undoubtedly, without any action of quinine, cause hemoglo- 
binuria. Also this infection may produce a nephritis. 

Pernicious malarial fever, so called congestive chills, is 
recognized as of great danger to the patient; therefore intensive 
treatment with quinine is necessary. If there is not time be- 
fore the expected next chill for the absorption of a large dose of 
quinine, perhaps 40 to 50 grains, it has been advised to give the 
drug either subcutaneously, intramuscularly, or intravenously. 
It seems that intramuscular or subcutaneous injections of 
quinine are hardly safe, even in the form of the quinine and urea 
hydrochloride, as serious destruction of tissue may be caused. 
Also intravenous injections may cause serious symptoms, 
especially if the blood-pressure is low. 

In so-called chronic malarial poisoning, often associated with 



368 THE PRINCIPLES OF THERAPEUTICS 

an enlargement of the spleen, various treatments have been 
suggested, all with quinine as a basis. Hydrotherapeutic 
measures, sweating treatments, and the administration of iron, 
arsenic and quinine represent the best treatment. 

For patients who cannot take quinine and who have malarial 
fever, arsenic and methylene blue are the best, but poor, 
substitutes. 

Other Uses. — Quinine in small doses has long been used as 
a tonic. It increases the appetite and tends to raise the blood- 
pressure. 

The dihydrobromide of quinine is many times very successful 
in the tachycardia of Graves' disease. The dose must be large, 
at least 0.30 Gm. (5 grains) three times a day, and it must 
be given for some time. The disagreeable cinchonism at first 
caused is soon not in evidence, and the drug is generally well 
tolerated. 

The anesthetic properties of quinine and urea hydrochloride 
have been much lauded, especially to cause desired necrosis. 
It would seem hardly safe to inject this drug into the thyroid 
gland in Graves' disease, although it has been advocated. The 
use of the drug to destroy tissue has been well described by 
Babcock. 1 The first sensation caused by this drug, when in- 
jected, is intense burning, which is soon dulled by the anesthetic 
action. When injected under the skin Babcock states that 
the tissue becomes at first anemic, then necrotic, and a few 
days later there is a black eschar. When injected into mucous 
membrane, the black eschar does not occur. There is likely 
to be a good deal of edema develop in the region of the injection, 
and there also is considerable danger of a patient having an 
idiosyncrasy against quinine and developing unpleasant 
symptoms. An idiosyncrasy could probably be readily deter- 
mined by the skin antigen tests, as above suggested. Babcock 
believes this anesthetic destroyer of tissue may be valuable 
to use in port wine stains or birth marks, for some growths on 
the skin, and to destroy warts and moles . 

This drug may be obtained in ampules, from a few drops to 
2 mils of which may be injected, depending upon the area it is 

1 New York Med. Journ., March 3, 191 7, p. 385. 



SERUMS IN HEMORRHAGE 369 

desired to destroy. It would seem that other methods of 
cauterization and destruction of tissue would be safer. 

SERUMS AS SPECIFICS IN HEMORRHAGE 

The drugs used to stop external bleeding have been termed 
styptics. The best for local use are peroxide of hydrogen 
solutions; ferric salts; suprarenal extracts; ice; and, perhaps, 
cauterization. It should not be forgotten that the most effec- 
tive means of stopping external bleeding is by pressure, either 
at the point of bleeding or on the artery above. 

The method used to stop internal bleeding depends somewhat 
upon the location of the bleeding part, but anything that 
lowers blood-pressure and quiets the heart's action tends to 
stop hemorrhage; hence rest, quiet, and at times, in nervous 
excitement, small doses of morphine, if the hemorrhage has not 
been too great in amount, are of great benefit in causing the 
bleeding to cease. 

Nitroglycerin is valuable in lowering blood-pressure and in 
stopping internal hemorrhage, especially in hemoptysis. It is 
a mistake to give drugs that raise the blood-pressure during 
hemorrhage unless that hemorrhage is venous and is due to 
insufficiency of the heart. Venous bleeding is likely to be 
from the nostrils, or it may be from the lungs In such a case 
digitalis will be of benefit, although it does not act until some 
hours after it has been administered. In most internal hemor- 
rhage, strychnine, suprarenal, atropine, caffeine, ergot, tyra- 
mine, etc., are contraindicated. Ergot is of value in uterine 
hemorrhage when the uterus is dilated, as it contracts that organ, 
and therefore closes the bleeding vessels. 

Bleeding from the nose may be checked by cotton tampons, 
dry or soaked in peroxide of hydrogen solution or in some more 
active styptic, or by post-nasal packing. Applications of an 
epinephrine solution may stop the hemorrhage, but it is likely 
later to cause local congestion. 

Hemoptysis may be checked by rest, nitroglycerin, and 
morphine in a small dose if needed. Repeated bleeding may 
require calcium, digitalis, or some serum injection, and possibly 
the injection of gas or air into the pleural cavity. Hematemesis 

24 



370 THE PRINCIPLES OF THERAPEUTICS 

may be stopped by a suprarenal solution taken into the stomach, 
or by swallowing ice, and by rest. 

Intestinal hemorrhage may be combated by some tannic acid 
preparation, as pro tan ( tannin nucleo-proteid"), by gelatin, 
by calcium, and by rest. Morphine may be necessary to 
cause peristaltic rest. Kidney hemorrhage perhaps is well 
treated by gallic acid. It is doubtful if cotarnine salts, as 
cotarnine hydrochloride or cotarnine phthalate (styptol) are 
of any value. 

Of course it is understood that in every case of internal 
bleeding, the exact cause must, if possible, be determined, and 
often surgery must be invoked to cure the condition of which 
hemorrhage is a symptom. If the blood does not normally 
coagulate, calcium must be administered in the form of lime 
water or as calcium lactate, and plenty of milk must be given. 

Thromboplastic substances and fibrin ferments, brain extract 
and so-called kephalin and coagulin are described on pages 371, 
and 509 but the serum from blood seems to be the most active 
coagulant that we can administer. 

The blood serums used are from the human, from the horse, 
and from the rabbit. The serum of the rabbit is perhaps more 
similar to human serum than that of the horse, but horse serum 
is always available, as it can be obtained in sterile ampules or 
in the form of diphtheria antitoxin, and when other serum 
cannot be obtained, the contents of an ordinary tube of diph- 
theria antitoxin, representing the fewest units, may be injected. 
Subcutaneous injection of course is a slower therapeutic method 
than the intravenous injection. It must be known whether 
the patient is susceptible to the emanations of the horse, i.e., 
whether he has any hay fever or asthma when in the region of 
a horse or a stable, else serious poisoning, serum sickness, may 
be caused. 

Theoretically when it can be obtained, normal human serum 
from a person who is known not to be diseased, and in whom the 
Wassermann test is negative, is the best serum to use. From 
10 to 20 mils of the serum may be given to hemophiliac patients 
daily for a short time, until the bleeding stops. While human 
blood should not be administered intravenously to a patient 



COLCHICUM FOR GOUT 37 1 

unless the tests have been made to show that the donor's blood 
is not destructive to the recipient's blood, serum from a donor 
may be injected without such an examination. At the present 
time transfusion has become so successful that, when possible, 
it should be the treatment for a hemophiliac or for one who 
has a serious hemorrhage, unless more simple treatments are 
quickly successful. 

At times profuse bleedings occur on account of endocrine 
gland disturbances, and sometimes the administration of 
thyroid extract is successful in stopping such bleedings, and 
at other times suprarenal extract is successful. 

Coagulose, which is a dried product prepared from horse 
serum, comes in ampules, ready for use. It may be placed dry 
on a bleeding surface, or it may be dissolved in sterile water 
and injected subcutaneously. The whole contents of the 
ampule, representing about 10 mils of the fresh serum, may be 
injected and repeated, every few hours if deemed advisable. 

Gelatin may be dissolved and given for hemorrhage from the 
stomach and intestines, and may be of some value, when 
absorbed, for other forms of internal hemorrhage; but to inject 
preparations into the muscle tissues, even if sterile, is inadvis- 
able. If gelatine is used for injection purposes it must be 
thoroughly sterilized, as it may contain the germs of tetanus. 

Thromboplastin solutions for injection come in sealed vials 
containing 20 to 25 mils of the solution. These preparations 
are likely to deteriorate, and therefore should be kept where 
they are cool, like other serum products, and should be dated. 



CLASS VIII 

Drugs Used as Specifics 
colchicum in the treatment of gout 

The cause of gout is unknown, but it is of interest to note 
that as arthritis deformans, which is due to some focal infection, 
is more and more frequently recognized, gout is becoming less 
frequent. However, there is a disease or a condition of gout, 
and the tendency to gout is inherited. 



372 THE PRINCIPLES OF THERAPEUTICS 

At the present time gout need not be listed with the infec- 
tions, but rather with the metabolic disturbances, and it seems 
to be due to some mistake in the nitrogen metabolism some- 
where from intake to output. 

It also seems to be a fact that the more purins ingested, 
the more the gouty symptoms in gouty patients. However, 
uric acid is not a cause of gout, and "uric acid diathesis" and 
"uricacidemia" are not good terms. Still, in acute gouty 
disturbances the uric acid output is likely to be diminished, and 
relief occurs when the output of that substance is increased. 

It is not necessary here to discuss the relationship of the 
liver to gout, except to note that urea is largely formed and 
uric acid largely destroyed in that organ, and a disturbance 
of the liver might be a cause of gout. Also, doubtless the 
suprarenals and the thyroid take part in nitrogenous metab- 
olism, and generally in gout intestinal mal-function is in evi- 
dence. Also the gonads play some part in the development 
of gout. 

As to food for gouty patients it is necessary only to state 
that the purins should be removed from the diet, except that 
meat may be allowed once a day. Some gouty patients are 
always disturbed if they ingest certain purins, and a gouty 
patient perhaps generally has a higher percentage of uric acid 
in his blood than is the normal average. 

To properly treat gout we must carefully study the functions 
of each organ, and study the nitrogen and uric acid excretion in 
the urine on a known diet. The foods and liquids found to 
cause the least disturbance (to be the best digested and the 
best excreted) should be the diet for each particular patient. 
Whatever acute conditions are present should of course be 
treated. In other words, there is no one way to treat or manage 
chronic gout, and a food that is inadvisable for one patient 
might be perfectly well taken care of by the next patient. Even 
to order an increased amount of water drunk may be a mistake 
for some patients, although more water than these gouty patients 
ingest is generally advisable. It is not proposed to discuss the 
whole treatment of gout, but only the value of colchicum in 
the treatment of that disease. 



colchicum 373 

Colchicum is of very little value in chronic gout, and in acute 
gout its greatest value may be due to its purgative properties. 
In subacute and chronic gout salicylates are not very satis- 
factory, although they may be of some value. Cinchophen 
(atophan), Acidum Phenylcinchoninicum, to increase the 
output of uric acid may be of great value, and pushing 
alkalies to increase metabolism and decrease acidity is often of 
value. 

Colchicum Seed — Administration. — Colchicum seed is best 
used in the form of the official tincture (Tinctura Colchici S 'em- 
mis, a solution representing 10 per cent, of the drug), the dose of 
which is 2 mils ( % a rluidrachm) . It should be given in sufficient 
dose to cause slight purging; too much purging should be pre- 
vented by proper treatment. Colchicum should always be 
administered in a liquid preparation. 

The alkaloid of colchicum is official as Colchicina (colchi- 
cine). This alkaloid occurs as pale, yellow scales or powder, is 
soluble in water, and the dose is 0.0005 Gm. (K20 grain). 
Pearls or capsules of this drug may be obtained in which the 
alkaloid is dissolved in oil of wintergreen. Such a preparation 
is much used in subacute gouty conditions. This is a very 
active alkaloid, and may cause some depression. 

Action. — When taken internally solutions of this drug may 
cause some gastric irritation, but if diluted, the bitter taste may 
increase the appetite. It is rapidly absorbed; may increase the 
secretion of the salivary glands and other digestive secretions; 
increases peristalsis; and in large doses acts as a purgative. It 
may slightly depress the nervous system, slow the heart, and 
lower the blood-pressure. The output of urine is often in- 
creased under the action of colchicum, and, if there is 
increased temperature in an exacerbation of gout, per- 
spiration may be caused by the full action of this drug. It is 
excreted partly through the intestines and partly through the 
kidneys. 

Over-action. — The only over-action of colchicum is purgation 
and some circulatory depression, though there may be vomiting 
and abdominal pain. If such a condition is not properly treated, 
collapse might occur. 



374 THE PRINCIPLES OF THERAPEUTICS 

Toxic Action. — Rarely serious poisoning may occur from a 
very large dose of colchicum. The main symptoms are gastro- 
enteritis with bloody stools, intense colics, and collapse. The 
condition is difficult to cure, but fortunately such poisoning is 
exceedingly rare. 

Treatment of Poisoning. — The treatment of poisoning is to 
give an emetic if it is considered that part of the drug is still in 
the stomach, and to hasten the movement of the drug through 
the intestines by a saline purgative, and later to stop the peris- 
talsis and colic by a hypodermic of morphine and atropine. 
The usual soothing treatments should be given to the gastro- 
intestinal canal. Of course, if prostration is present it is inad- 
visable to give emetics or purgatives. In that case, tannic acid 
should be given, and supporting treatment, as caffeine, atropine, 
and perhaps strychnine. 

Uses. — There is no therapeutic use for colchicum except in 
gouty conditions, and, as stated, it is of little value in chronic 
gout. Also when joints are acutely inflamed, due to gout, it is a 
question if free purgation and the administration of salicylates 
will not be of as much benefit as colchicum. Colchicum should 
never be administered, if there is acute gastric or intestinal 
inflammation, neither should it be pushed in debilitated 
patients. 

Although it has been thought that the preparation of the 
root is better than the preparation of the seed, also that 
the wine of the root is the best preparation, it is probable that 
colchicum is colchicum, and if a good preparation of the seed is 
given in sufficient amount, the action must be the same as with 
any other form of colchicum. 

At times alkalies seem to be of value in gout, and the best is 
potassium citrate. There is absolutely no use for lithium, either 
as a drug, or in waters containing Hthium. They have no sol- 
vent properties on uric acid or urates or any other concretions. 
The multitude of "anti-gout" preparations, mostly supposed 
to contain Hthium, and all supposed to prevent the formation of 
uric acid and increase the output of uric acid, are all inefficient, 
useless remedies. The best preventive of the formation of con- 
cretions is distilled water. 



SALICYLIC ACID 375 

SALICYLIC ACID IN THE TREATMENT OF RHEUMATISM 

While salicylic acid is not a real specific for acute rheumatism, 
it is the most efficient drug that we possess for modifying the 
joint pains, safely reducing the temperature, and promoting 
eliminating perspiration in that disease. 

As there are many joint disturbances that are misnamed 
rheumatism, it may be well to first define what is rheumatism, 
and especially the kind of rheumatism that is best treated by 
salicylates. Acute rheumatism, rheumatic fever, is an infec- 
tious disease, probably rarely contagious, caused perhaps by 
several germs, characterized by inflammation of the structures 
in and around joints, namely, arthritis, and with a very decided 
tendency to cause inflammation of the heart. So-called sub- 
acute rheumatism is simply a mild attack of acute rheumatism 
without much fever, without the tendency to migrate from joint 
to joint, but with the same tendency (only not as decided) to 
affect the heart. Chronic arthritis, arthritis deformans, and 
gouty arthritis are entirely different conditions, in which the 
salicylates are not of much value. 

The infection of acute rheumatism most frequently enters 
the body through the tonsils, hence infected tonsils are a menace. 
Recurrent follicular tonsillitis makes the individual likely to 
develop acute rheumatism at any time. Children and youth, 
who are more likely to have enlarged and diseased tonsils, are 
the ones most likely to have this disease and chorea, a closely 
allied disease. Chorea, as well as inflammatory rheumatism, 
frequently causes the serious complication of endocarditis. 
Also both acute and chronic endocarditis may develop in chil- 
dren and adults from infected tonsils and teeth without any 
joint trouble appearing; hence the menace of these focal infec- 
tions. It may here be interpolated that the greatest menace in 
the United States to-day is that of crowned, bridged, and 
pivoted teeth. Arthritis deformans is due to infection, mostly 
from the mouth. 

The germs that cause rheumatism and chorea are not pus- 
forming, hence the infected joints and tissues do not suppurate. 
It has been thought that one attack of rheumatism predisposes 
to another, probably because the focal infection has not been 



376 THE PRINCIPLES OF THERAPEUTICS 

eradicated. However, the disease does not confer an immunity, 
and hence may be repeated. 

This is not the place to discuss the advisability of eradicating 
enlarged tonsils, but certainly there can be no question of the 
advisability of removing all diseased portions of tonsils and all 
focal mouth infection. 

Salicylic Acid. — Salicylic acid exists in natural combination 
in various plants, and is also prepared synthetically. It occurs 
as fine needles or crystalline powder, has a sweetish/acrid taste, 
and is slightly soluble in water. The dose is 0.75 Gm. (12 
grains). 

Sodium Salicylas. — Sodium Salicylate occurs as a white crys- 
talline or amorphous powder, has a sweetish taste, and is very 
soluble in water. The dose is 1 Gm. (15 grains). Sodium 
salicylate does not keep well in weak solutions. 

Methylis Salicylas, (Oil of wintergreen; oil of betul; oil of 
sweet birch). — Methyl salicylate is made synthetically or is 
produced by distillation, and the label should designate by 
which method the preparation is obtained. It occurs as a 
yellowish or reddish liquid with the odor and taste of winter- 
green. The dose is 0.75 mils (12 minims). 

Acidum Acetylsalicylicum. — Acetylsalicylic acid (aspirin) 
occurs as small crystals or as a white crystalline powder. It 
has an acid taste, is slightly soluble in water, and the dose is 
0.30 Gm. (5 grains). 

Administration. — Salicylic acid is more irritating to mucous 
membranes than is sodium salicylate. Also sodium salicylate 
is much more soluble, and hence more readily absorbed. There 
is, therefore, rarely any excuse for giving salicylic acid internally 
in preference to sodium salicylate. As sodium salicylate has a 
wintergreen taste, it is well to give it dissolved in wintergreen 
water, and a prescription containing 1 Gm. of sodium salicylate 
to 5 mils of wintergreen water is a useful one, as it may be given 
in 3^2 teaspoonful, teaspoonful, or 2 teaspoonful doses, as deemed 
necessary. Both salicylic acid and sodium salicylate should be 
given well diluted. Syrup of orange or syrup of ginger may be 
added to a sodium salicylate liquid solution, if the sweet winter- 
green taste is especially disagreeable to a patient. 



SALICYLIC ACID 377 

Methyl salicylate is not much used internally, although there 
is no good reason why it should not be, provided it is well 
diluted and the stomach is not empty. Methyl salicylate is 
frequently used in ointments or liniments on rheumatic joints. 

Acetylsalicylic acid (aspirin) is now very popular for colds, 
headaches, muscle pains, and joint pains, but in rheumatism it 
cannot be pushed to the point of salicylism as effectively or as 
safely as is sodinm salicylate. Aspirin is more sedative in 
painful conditions not due to rheumatism. On the other hand, 
it is more or less of a cardiac depressant and it should be recog- 
nized that whenever aspirin in full doses is given the patient 
should remain at rest, as he has taken a drug that acts not un- 
like acetphenetidin. 

There has long been a discussion as to whether synthetic 
salicylic acid preparations were more depressant to the heart 
than natural salicylic acid preparations. Clinical and labora- 
tory experiments have seemed to show that there is no difference 
in the toxicity of the two kinds of preparations. Also thera- 
peutically natural oil of wintergreen seems to be of no greater 
value than the synthetic preparation, methyl salicylate. 

There are very many salicylic acid preparations on the 
market, proprietary preparations which are supposed to offer 
salicylic acid action without the sting of salicylic acid, i.e., they 
do not disturb the stomach, and are supposed to be as efficient. 
These drugs do not represent nearly as much salicylic acid, dose 
for dose, as does sodium salicylate, hence to obtain the same 
action and effect very much larger doses must be given, and 
with such doses the same unpleasant symptoms as with sodium 
salicylate will generally occur. 

Salicylic acid is strongly antiseptic and mildly escharotic, 
and a 10 to 20 per cent, ointment of salicylic acid will remove 
warts and callous skin. An efficient solution for this purpose is 
made by dissolving 1 Gm. of salicylic acid in 30 mils of collodion. 

Action. — Salicylic acid as such is irritant to the skin and 
mucous membranes, and, when taken into the stomach, will 
cause nausea and vomiting, as well as irritation and inflamma- 
tion, unless it is well diluted. All salicylic acid preparations, 
except those insoluble in the stomach, slow digestion. Salicyl- 



37$ THE PRINCIPLES OF THERAPEUTICS 

ates are rapidly absorbed, and soon appear in the urine as 
salicyluric acid. Salicylic acid seem to be slightly stimulant 
to the liver, and may increase the secretion of bile. 

Small doses do not much affect the circulation. There may 
be slight stimulation of the heart, perhaps a slight increase of 
blood pressure, but large doses may depress the heart. With 
full doses the rapidity of the heart is increased, there is a feeling 
of fullness of the head, ringing in the ears (and there may even 
be deafness) , and flushing of the face. This condition is termed 
salicylism, and is very similar to cinchonism. 

Normal temperature is not much affected, but in feverish 
processes the temperature is reduced, and the perspiration is 
increased, especially in rheumatic fever. All salicylates in- 
crease waste metabolism, and the body loses weight under their 
full action. 

Salicylates are excreted chiefly by the kidneys, partly as 
salicylic acid, partly as salicyluric acid, and perhaps in part as a 
salicylate. Some of the salicylic acid may be excreted in the 
sweat, and some in the feces, and some may be destroyed or 
retained in the body. There is at first an increased excretion 
of urea and uric acid, although the function of the kidneys may 
be soon disturbed. Hanzlik and Karsner 1 found that full doses 
of salicylates very easily cause albumin to appear in the urine; 
that renal function, on repeated full doses, is soon impaired; and 
that urea nitrogen accumulates more or less in the blood. 
Hanzlik and others found the administration of bicarbonate of 
sodium with the salicylate does not prevent this bad effect of 
the salicylates. 

Fan tun, Simmonds and Moore 2 found that sodium salicylate is 
not well tolerated in animals infected with hemolytic strepto- 
cocci, and that the coincident administration of sodium bicar- 
bonate does not prevent this harmful action. They also found 
that acetylsalicylic acid (aspirin) was more toxic to normal 
animals than sodium salicylate, and also harmful to infected 
animals. 

These experimenters apparently demonstrate that salicylic 

1 Archives of Internal Medicine, June, 1917, p. 1016. 

2 Archives of Internal Medicine, April, 191 7, p. 529. 



SALICYLIC ACID 379 

acid in any form should be used, if at all, with great care when 
the kidneys are imperfect. Also, that salicylic acid should not 
be given in any general infection except as a specific in acute 
rheumatic fever. However, salol in small doses may be of 
benefit as a bowel antiseptic in typhoid fever, but the dose 
should always be small, and it should be stopped as soon as 
albumin is discovered in the urine. 

Over-action. — Over-action from salicylates is evidenced by the 
symptoms above described, termed "salicylism;" by flushing of 
the face and of the whole skin; by erythemas and urticarias; 
sometimes by rapid heart action; by albuminuria; and by 
great diminution of the amount of urine, or suppression. All 
of these symptoms generally quickly disappear on stopping 
the drug, giving alkalies, large amounts of water, and adminis- 
tering a bromide. 

Toxic Action. — More serious poisoning may be caused by 
large doses of salicylates, in which the sight is impaired, the 
patient becomes deaf, has dyspnea, may be delirious, and may 
even become collapsed and have a weak pulse and cold perspi- 
ration. Patients who are suffering from cerebral disturbances, 
as in alcoholism, seem to have more of the head symptoms 
from salicylates than patients who have not such disturbances. 
Occasionally hemorrhages have been caused by salicylates, 
either nasal or uterine. 

Treatment of Poisoning. — Patients severely poisoned by this 
drug should receive not only the treatment above suggested 
for over-action, but also, if collapsed, require cardiac stimulants, 
and should be surrounded by dry heat. 

Uses. — Sodium salicylate is generally the drug of preference 
in acute rheumatism, and it acts almost specifically in quieting 
the pain, lowering the temperature, and modifying the intensity 
of the whole disease. It has not been shown that it will shorten 
the disease or abort it, but it does make the patient's condition 
more comfortable. Morphine may be needed to assist in 
stopping the pain before the salicylate has reached its full 
effect. It seems generally advisable to push the drug until 
some signs of salicylism are present, and the adult dose of 
sodium salicylate is 1 Gm. (15 grains) administered, at first, 



380 THE PRINCIPLES OF THERAPEUTICS 

four or live times in twenty-four hours. As soon as signs of 
salicylism develop, the frequency of the dose may be diminished. 
If, in acute rheumatic arthritis, the patient is not improved by 
this drug in four or five days, or at least at the end of a week, 
the salicylic acid treatment should be stopped and other drugs 
substituted. Coincidently, or certainly after the drug is 
stopped, alkalies seem to be the best treatment. 

As above stated, acetylsalicylic acid is too depressant to 
push to full physiologic effect in acute rheumatic arthritis; 
it is much more depressant to the heart than sodium salicylate. 

If desired, an effervescing mixture may be prepared, as: 
salicylic acid, 1 gram, and sodium bicarbonate, 1 gram. This 
powder, which is placed and kept in waxed paper, when dis- 
solved in a glass of water, makes a pleasant effervescing drink. 
Oil of wintergreen may be given in a dose of 1 mil (15 minims) 
either in ready prepared capsules, or dropped into some demul- 
cent drink. It should not be given on an empty stomach. 
Oil of wintergreen (methyl salicylate) may be rubbed over the 
affected joints, or applied on cotton to the joints. 

It has been considered by some physicians that after a patient 
is convalescent from acute rheumatism, it is well to give another 
few days of treatment with salicylic acid in some form. 

As salicylates all promote waste and seem to more or less 
destroy or prevent the development of red corpuscles, all these 
rheumatic patients become anemic, and they require iron as 
soon as the acute fever has passed. If the feverish process is 
prolonged, they should be given iron in small doses, daily, and 
should receive iron during convalescence and for a long period 
thereafter. 

If endocarditis develops, it is generally considered best 
to stop the salicylate, especially as it has been shown that 
salicylic acid does not abort or shorten the rheumatic attack, 
it only makes it more comfortable. It is not a specific anti- 
dote to the disease. 

After every attack of acute rheumatism the patient should 
be carefully studied for focal infections, especially of the 
tonsils and mouth, and if foci of infection are found they 
should be eradicated before another attack develops. 



SALICYLIC ACID 381 

As above stated, other forms of rheumatism are not as suc- 
cessfully treated with salicylates, with the exception of subacute 
arthritis. However, in many patients who seem to be rheu- 
matic and who have sciatica or other neuralgic conditions due 
to some infection or to some uric acid mistake in the metabolism, 
salicylates, given for a few days, often improve the condition. 
Of course in every such case the diet should be so regulated as to 
remove most purins, and frequently meat should be stopped 
entirely, and patients with acute rheumatism should generally 
not be allowed meat for several weeks. Although uric acid is 
not the cause of rheumatism, it may be increased in amount and 
be retained in rheumatic conditions. Also, these patients are 
very generally hyper-acid, and are much benefited by alkaline 
treatment, and are frequently improved by a vegetable protein 
and carbohydrate diet. 

Contraindications to the use of salicylates are cerebral 
inflammations and disturbances, disease of the ear, deafness, 
acute cardiac inflammation, and nephritis. 

Phenyl Salicylate (Salol). — Phenyl salicylate occurs as a 
white crystalline powder, has an aromatic odor, is insoluble in 
water, and the dose is 0.30 Gm. (5 grains). 

Phenyl salicylate (salol) should not often be used in rheuma- 
tism. Its greatest efficiency is as an antiseptic in the bowels 
and in the urinary tract. When this drug is given in too fre- 
quent or too large doses, poisoning occurs, with black urine and 
the nervous disturbances caused by its phenol. Occasionally 
it may cause salicylism. 

Salol is not dissolved in acid media, but breaks up in the 
intestine into its component parts of phenol and salicylic acid, 
and, therefore, acts more or less as an antiseptic in the upper 
part of the intestines and tends to prevent putrefaction and fer- 
mentation, and causes constipation. In any acute diarrhea salol 
is a most efficient remedy, always provided there is no albumin- 
uria or other serious disturbance of the kidneys, as it should not 
be given when the kidneys are in trouble. 

Acute diarrhea is well treated by a purgative, followed by 
bismuth subcarbonate 1 Gm. (15 grains), and phenyl salicylate 
0.30 Gm. (5 grains), one such powder given every two or three 



3S2 THE PRINCIPLES OF THERAPEUTICS 

hours for ten doses. Most diarrheas will stop with such treat- 
ment. 

In typhoid fever salol is frequently given as a bowel anti- 
septic, and the dose should be 0.25 Gm. (4 grains), in capsule, 
once in six hours, unless the kidneys are in trouble. It may be 
given throughout the acute illness, if some other treatment is 
not preferred. It may prevent the typhoid germs from migrat- 
ing upwards in the intestine, and the typhoid and colon bacilli 
from locating in the pelvis of the kidney. There is no question 
of the antiseptic action of salol in the upper part of the intestines, 
and also in the kidneys and bladder. 

Salol has been much used in infection of the pelvis of the kid- 
ney and in infection of the bladder, and also in specific urethri- 
tis. Hexamethylenamine has more or less supplanted this drug, 
but salol is many times a valuable treatment during acute in- 
fection of these parts. It has been thought, in specific urethri- 
tis that it at times prevents the gonococci from reaching the 
posterior urethra and bladder. 

Salol is not a good treatment in acute rheumatism, as in 
such a condition the dose must be large and phenol poisoning 
would be readily caused. 

CLASS IX 

Drugs used to Modify Metabolism 
arsenic 

Arsenic in sufficient dose is a germicide, and is especially 
efficient in combating certain germs. In large doses it is a 
promotor of waste metabolism to the point of destruction of 
tissue and stoppage of function. In small doses it is stimulant 
to most functions of the body, and if not too long continued acts 
as a tonic, and may cause increase of weight. Repeated over- 
doses or long continued small doses may seriously impair the 
suprarenal glands. 

Arseni Trioxidum (White Arsenic).' — Arsenous acid occurs as 
a white substance, is tasteless but soon irritant, is soluble in 
water, and the dose is 0.002 Gm. (3^o grain). The most used 
preparation is the Liquor Potassii Arsenitis, (Fowler's Solution), 



ARSENIC 383 

which is a 1 per cent, solution of arsenous acid, and the dose is 
0.2 mil (3 minims). 

Arseni Iodidum. — Arsenic iodide occurs as an orange-red 
crystalline powder, is soluble in water, and the dose is 0.005 
Gm. (K2 grain). 

Sodii Cacodylas (Sodium Dimethylarsenate) . — Sodium caco- 
dylate occurs as a white granular powder, is very soluble in 
water, and the dose is 0.06 Gm. (1 grain). 

Sodii Arsenilas (Atoxyl) occurs as white crystals, which are 
soluble in water, and the dose is 0.02 Gm. (J^ grain). This drug 
should not be given by the mouth, as it is likely to be decom- 
posed by the acid of the stomach and cause poisoning. It is 
intended for hypodermatic administration in the dose above 
suggested. The dose may be increased, as with any other 
arsenic treatment, to the point of tolerance. It is best admin- 
istered every other day, so that it will not be as likely to accumu- 
late in the system. 

This preparation has largely been recommended in anemias 
and in certain diseases of the skin, but, like any other arsenic 
treatment, it may cause serious symptoms, as destruction of 
blood corpuscles and optic neuritis. 

The arsphenamine preparations are described on page 347. 

Administration. — When arsenic is given in small doses for its 
stimulating effect on metabolism, or as a stimulant to the blood- 
forming organs, it may be given in solid form, as the arsenous 
acid, and is well given in a soluble tablet, or in a pill or capsule, 
or in the form of the sodium cacodylate. This latter preparation 
has, however, no apparent advantage over the older trioxide of 
arsenic. When it is desired to push an arsenic treatment, 
it should be administered in solution, and the best solution is the 
Liquor Potassii Arsenitis (Fowler's Solution). This may be 
administered in drops, gradually increased to the point of toler- 
ance, and there is no possibility of any accumulation of this soluble 
form of arsenic in the gastrointestinal canal. If it is deemed 
best to give the arsenic hypodermatically for systemic effect, the 
sodium arsenilas is perhaps the best form. For intravenous 
treatment and for intraspinal treatment, mostly in syphilis, 
arsphenamine or neoarsphenamine are the preparations to use. 



384 THE PRINCIPLES OF THERAPEUTICS 

Action. — Locally strong preparations of arsenic are escharo tic, 
but arsenic should rarely be used for that purpose; other treat- 
ments to destroy tissue are preferable and much less painful. 

Arsenic is more or less rapidly absorbed from the stomach and 
intestines, and many times acts as a stimulant to the organism, 
increasing the appetite, improving digestion, causing the patient 
to add weight by the deposition of fat, improving the nutrition 
of the hair, nails and skin, increasing the exfoliation of the epi- 
dermis, and causing a more healthy nutrition of the skin in 
general. For this purpose arsenic is often used in the scaly, 
dry skin diseases. 

After absorption into the blood, arsenic is found chiefly in the 
corpuscles rather than in the serum. It is a stimulant to the red 
bone-marrow, and increases the production of red corpuscles up 
to a certain point. Therefore it is of advantage in many cases 
of anemia, and has been used largely in pernicious anemia and in 
leukemia. However, when the drug is pushed, or has been 
given for some time, there may occur a rapid destruction of red 
corpuscles, the arsenic seeming to have a hemolytic effect. 
Sometimes in such conditions as lymphatic leukemia the white 
corpuscles are occasionally increased in number by the action 
of this drug. 

Arsenic seems to be a stimulant to all glandular tissues, and 
probably to the thyroid. It has often been used to reduce the 
size of enlarged lymphatic glands, especially of the neck. Its 
success is perhaps largely due to its germicidal effect on what- 
ever organism was causing enlargement of the glands. It is also 
quite probable that its good effect in pernicious anemia and 
leukemia is because it acts as a germicide to the infecting or- 
ganisms that are probably causing these diseases. These 
diseases are probably due to some focal infection, the germs of 
which may frequently enter the body by the way of infected 
areas in the mouth. Arsenic has no special action on the heart 
or blood-pressure or on the central nervous system, unless 
poisoning occurs. 

Arsenic is chiefly eliminated in the urine, but is found after 
it has been given for some time in the feces, in the bile, in the 
perspiration, and in the milk of nursing women. The rapidity 



ARSENIC 385 

of elimination varies. A single dose may be entirely eliminated 
in a few hours, or it may not be eliminated for several days, and 
after many days of treatment the urine may contain arsenic for 
one or two months, or even longer, after the cessation of the 
administration. 

Over-action. — When during the administration of arsenic the 
limit of tolerance to it has been reached it is evidenced by 
nausea, vomiting, diarrhea, red eye-lids, puffing under the eyes, 
skin eruptions, and albuminuria. If any of these symptoms of 
primary poisoning develop, the arsenic should be stopped, and 
generally the symptoms quickly disappear. 

In some diseases, typically chorea, pernicious anemia, and 
leukemia, it has been deemed advisable, after the appearance of 
these symptoms and after their abatement, due to stopping the 
drug for a few days, to start again with a dose less than the dose 
that was given when the symptoms were caused and to gradu- 
ally increase the dose to the point when intolerance is again 
shown by the above symptoms. After another period of in- 
termittency the drug may be given again to a third point of 
intolerance. After another intermission the drug may be 
given for some time at a dose less than that which caused the 
symptoms at the third point of intolerance. The exact value 
of the 'drug given in this manner is questionable. However, 
some success in causing a remittance of the disease has fre- 
quently been recorded in pernicious anemiaand leukemia. As 
above stated, probably these diseases are due to infection and 
the infection is overcome by the arsenic. Chorea is a self- 
limited disease, and probably is due to an infection, but it is 
hardly excusable to use the poison, arsenic, in this disease. 

When arsenic is pushed to its full primary toxic effect it 
may do serious harm in causing multiple neuritis, dermatitis, 
destruction of red corpuscles, a greatly disturbed digestion, 
exhaustion, prostration, and fatty degeneration of some organs, 
i.e. 7 chronic poisoning may develop. 

Toxic Action. — The symptoms of a toxic dose of arsenic may 
appear within a few minutes, or not for an hour or more after 
such a dose has been taken, depending upon whether, or not, the 
stomach is empty. There is often pain in the mouth, throat, 

25 



386 THE PRINCIPLES OF THERAPEUTICS 

esophagus, stomach, and finally over the whole abdomen. 
There is nausea, vomiting of the contents of the stomach, then 
of mucus, and often of blood; soon loose movements of the 
bowels occur, accompanied by intense colicky pains. The 
pain is so severe as to cause more or less cardiac shock, and 
soon, heart failure. There is dizziness and headache, and con- 
vulsions may occur. 

In a short time, provided the patient does not die soon from 
shock, the urine becomes scanty and albuminous, and there 
may be tenesmus and strangury, and finally suppression. 
Soon intense thirst develops, with a dry mouth and tongue, 
and distention of the abdomen occurs. If the patient survives 
there is likely to be an eruption on the skin, which may be 
erythematous, petechial, papular, or vesicular. 

In poisoning from smaller doses long continued, or occasion- 
ally when the gastrointestinal symptoms do not cause death 
when large amounts are absorbed, paralyses occur, especially 
of the paraplegic type. There is often intense pain and cramps 
in the muscles of the extremities. In slowly developing poison- 
ing from large therapeutic dosage, multiple peripheral neuritis 
may occur. 

After poisoning, unless the patient soon dies, fatty degener- 
ation of the liver and kidneys develops, and if the drug is taken 
by the stomach there is likely to be localized inflammation of 
the stomach and intestines, with eroded areas and ecchymotic 
spots. 

Treatment of Acute Poisoning. — If a patient is not vomiting 
when first seen, he should drink freely of water containing the 
official arsenic antidote, namely, Ferri Hydroxidum cum 
Magnesii Oxido. This preparation is kept in drug stores in 
two bottles so that the mixture can be freshly made. The dose 
is at least 100 mils (about 3^ ounces). If vomiting does not 
quickly occur, the stomach should be washed out by means of 
the stomach tube. On account of the prostration that is 
almost sure to develop from arsenic poisoning, apomorphine, 
administered hypodermatically, is not advisable, as there is 
always prostration from this emetic. If a stomach tube is 
not at hand or the arsenic antidote is not at hand, milk and 



ARSENIC 387 

water should be immediately given, and if there is no vomiting, 
mustard water should be administered. 

Later, castor oil should be given, not only to soothe the 
mucous membranes, but to hasten the passage of the arsenic 
through the intestines. Large amounts of water and demulcent 
drinks, as starch water, flaxseed tea, or slippery elm tea, should 
be given frequently, not only to soothe the gastrointestinal 
membranes, but also to promote the excretion of the poison by 
the kidneys and to reduce their irritation to the minimum. 

If the pain is intense, and to prevent shock, morphine should 
be given hypodermatically, but unless the pain is intense it 
should be withheld, as it will inhibit the excretion of the ab- 
sorbed arsenic through the kidneys. The later complications 
of poisoning will suggest the treatment necessary. 

When acute poisoning does not cause immediate death, and 
in chronic poisoning, the suprarenals are probably seriously 
affected, and the administration of extracts of the whole 
suprarenal gland is advisable, and also injections of tyramine 
hydrochloride, which acts like epinephrine only less intensely 
and longer, are indicated. 

Chronic Poisoning. — Chronic poisoning from arsenic is due to 
the prolonged administration, or to the accidental ingestion for a 
long time, of arsenic in any form. Accidental poisoning from 
arsenic is perhaps more frequent than is noted, as arsenic is 
found in some metals, and is used in certain dyes and pigments. 
Probably with the restrictions in the use of arsenic in artificial 
coloring of wall papers, artificial flowers, boxes, cretones, toys, 
etc., such poisoning rarely now occurs, but it is still possible 
that accidental poisoning from such articles may be the cause 
of unexplained disturbances. Chronic poisoning, if arsenic 
articles are handled, may cause ulcers on the fingers; or if dust 
containing arsenic is inhaled, it may cause disturbances of the 
upper air passages and bronchial tubes and congestions in the 
eyes, or there may be stomach and gastrointestinal disturb- 
ances, if the arsenic is swallowed into the stomach. Various 
skin diseases may occur, with darkening of the skin, due to 
suprarenal disturbance. Other glands of the body may be 
disturbed, and anemia may develop; jaundice may occur, and 



388 THE PRINCIPLES OF THERAPEUTICS 

albuminuria may be present. There may also be sufficient 
suprarenal and pancreatic disturbance to cause sugar to appear 
in the urine. 

The nervous symptoms vary from depression to insomnia, 
but the principal nerve disturbances are due to multiple periph- 
eral neuritis, with the symptoms and consequences of that 
condition. 

Chronic poisoning from arsenic should be identified from 
chronic liver disturbance, suprarenal disease, and from other 
causes of anemia. Multiple neuritis from arsenic may resemble 
locomotor ataxia in its symptoms. Chronic lead poisoning 
causes neuritis more especially of the forearms. In alcoholic 
neuritis there is less likely to be skin disturbances, and more 
cerebral symptoms are present. Also peripheral neuritis may 
follow some serious acute infection. 

The treatment of chronic poisoning is, of course, to remove 
the patient from all possibility of the absorption of more arsenic; 
to promote the general health by fresh air, the best food, iron 
and other tonics; and to promote elimination by hot baths, by 
body baking, or by electric light baths, and possibly later, by 
the administration of small doses of sodium iodide, to hasten the 
elimination of arsenic that has been deposited in the tissues. 
All complications and whatever neuritis is present must be 
properly managed. Treatment to be successful must be carried 
out for a prolonged period of time, and chronic debility may be 
permanent in spite of treatment. 

TO STIMULATE METABOLISM 

Arsenic is used (1) as a tonic (small doses); (2) as a 
stimulant to the production of blood corpuscles; (3) as a germi- 
cide; (4) as a stimulant to the skin. 

Small doses of arsenic certainly seem, many times, to stimu- 
late the digestion and the general metabolism of the body, and 
also seem to stimulate the glandular tissues, particularly the 
thyroid. The dose is small for this purpose, from 0.00 1 to 
0.002 Gm. (}i to 3^30 of a grain) three times a day. It should 
not be too long continued. 

In some sections of the world there are, so-called, arsenic 



IODINE 389 

eaters, notably in some regions of the Alps, and these arsenic 
eaters think they have a better respiratory ability under the 
action of the drug. They become tolerant to large doses. 

To meet the second indication, namely, to increase the blood- 
corpuscles, arsenic has long been given, probably too much and 
too frequently. It does stimulate the blood-forming organs, 
but sooner or later may cause destruction of red corpuscles, 
therefore for that purpose alone it seems hardly indicated. 

As a germicide in syphilis, in malarial infections, and in some 
other infections as pernicious anemia and leukemia, arsenic 
certainly has efficient activity. Its use in syphilis has already 
been described. Its value in malarial infections, when qui- 
nine cannot be taken, seems established, and its use in anemia 
and leukemia has also been mentioned. Arsenic for these pur- 
poses should be pushed to the point of tolerance, but it should 
always be kept within the range of safety, as over-action can 
develop at any time. 

To meet the indication of a skin stimulant arsenic is used 
largely in chronic scaly skin diseases, typically in psoriasis. 
It may even be a question whether psoriasis may not be due to 
an infection, and, perhaps, therefore the reason that arsenic has 
been so long recognized as of value in this disease. It is not 
of much value in chronic eczemas, as it may even cause more 
itching and more disturbance. 

As a gland stimulant arsenic is sometimes indicated, and some 
lymph gland enlargements improve under the action of arsenic. 
The thyroid seems to be stimulated more or less by arsenic, and 
sometimes when there is loss of hair arsenic improves the con- 
dition, perhaps by stimulating the thyroid. 

As above stated, there seems to be no excuse for giving 

arsenic in chorea, and it has been used too much as a tonic and 

in too large doses in blood diseases. Arsenic is a poison, and 

should be used only when there is a distinct positive indication 

for it. 

IODINE 

Iodine is necessary for the welfare of the body, as in its ab- 
sence the thyroid gland cannot properly function, and normal 
thyroid activity is absolutely necessary for health, if not for 



390 THE PRINCIPLES OF THERAPEUTICS 

life. Iodides prevent sclerosis, more or less, and promote 
absorption of more or less organized abnormal tissue, perhaps 
by increasing the thyroid gland activity. The actual amount 
of iodine needed daily to supply the thyroid and satisfy the 
tissues that contain minute amounts is very little. 

The proprietary iodine compounds are legion, but the official 
sodium iodide and potassium iodide are sufficient for the iodine 
needs of the metabolism. The Sodii iodidum is the best, as the 
sodium element is less depressant than the potassium element, 
and other things being equal, it should be the drug of choice. 
If the dose of these proprietary "iodides without their sting" is 
made equivalent to the iodine dosage of sodium or potassium 
iodide, the patient will have the same symptoms as from the 
Pharmacopceial preparations. It has not been shown that the 
so-called organic preparations of iodine, except thyroid extracts, 
have any more beneficial action than the inorganic salts. 

Potassii Iodidum. — Potassium iodide occurs as crystals or as 
a white granular powder, is very soluble in water, and the dose 
ranges from 0.05 Gm. to 1 Gm. (about 1 to 15 grains) depending 
upon the action desired. The Unguentum Iodi of the Pharma- 
copoeia contains 4 per cent, of iodine, and may be used on the 
skin to cause absorption of the iodine, but it is somewhat 
irritant. 

Sodii Iodidum. — Sodium iodide occurs as crystals or as a 
white powder, is very soluble in water, and the dose is the same 
as that of potassium iodide. 

Administration. — Both sodium and potassium iodide should 
always be administered in solution. Often the saturated solu- 
tion in water is preferred, where a minim represents a grain of 
the drug. Iodides should not be combined with other drugs and 
preparations, as with many of them they are incompatible. If 
a preparation is to be used infrequently, as one dose a day, as is 
so many times advisable in thyroid insufficiency, the iodide had 
better be dissolved in some antiseptic solution, as camphor 
water. As above stated, the dose may be from as little as 0.05 
Gm., from one to three times a day or 0.10 Gm. once a day, up 
to the amount the physician deems advisable for the patient. 
The large doses once used in tertiary and secondary syphilis are 



IODINE 391 

inexcusable; most of the iodide was never absorbed but passed 
out of the body in the feces. 

Fairly large doses are sometimes of more benefit than small 
doses in certain forms of asthma, but more than 1 Gm. (15 
grains) three times a day is never needed, and 0.50 Gm. (7^ 
grains) three times a day is generally sufficient. If the iodide is 
dissolved in plain water, it is well given in a small portion of milk 
after meals; the milk entirely disguises the taste. If the iodide 
is taken well diluted after meals it will rarely disturb the stom- 
ach. Strontium iodide and syrup of hydriodic acid have no 
advantage over sodium iodide. If preferred the official tinc- 
ture of iodine may be administered in one drop doses, taken well 
diluted. The so-called water-soluble iodines are not needed. 

Action. — Iodine as an antiseptic and a parasiticide has already 
been discussed under another classification, pages 119 and 127. 
It is only necessary to discuss here the action of absorbed iodine 
and the absorbed iodine element of an iodide. 

In weak solutions iodine is not irritant to the mucous mem- 
branes. It is quickly absorbed, and more or less rapidly 
excreted in the urine, but a very small portion may remain in 
the body and be used for body purposes over and over again. 

Iodine is excreted in the saliva, and, with the food, is again 
swallowed and again utilized, and while most of one ordinary 
dose of iodine will be excreted in ten or twelve hours, when sev- 
eral doses have been taken or a large dose has been taken, it may 
be several days before it is all excreted. Iodides are not well 
excreted when there is kidney insufficiency. 

Iodides seem to stimulate the activity of the lymphatic glands 
and may increase the number of lymphocytes in the blood, 
especially in the lymphatic type of leukemia. Iodine also in- 
creases the bronchial secretion, and is stimulant to the tubercu- 
lous process in tuberculosis, therefore it is contraindicated when 
tuberculosis is present, as it may cause rapid breakdown of the 
tubercles and, consequently, dissemination of the tuberculous 
infection. On the other hand, in asthma and bronchitis when 
tuberculosis is not present, it is a stimulant to the mucous mem- 
branes and causes a more healthy secretion, and may finally cure, 
or at least temporarily arrest, the condition. 



392 THE PRINCIPLES OF THERAPEUTICS 

When in subacute bronchitis the secretion is adhesive, in- 
sufficient, and difficult to expectorate, an iodide is the proper 
treatment, as it moistens and relieves the congestion of the 
mucous membranes and promotes normal secretion. It is 
especially valuable in the dry cough of tracheitis, and sometimes 
in a lingual tonsil cough, as normal mucous secretion of the 
throat, larynx, trachea, and larger bronchi is necessary for 
health and comfort, and a dry condition causes irritation and 
cough. 

The necessity for iodine for the normal activity of the thyroid 
gland need nQt be here discussed, as it will be taken up under 
the discussion of that gland. 

Over-action. — Over-action of an iodide is shown by some slight 
digestive disturbance; a disagreeable metallic taste in the 
mouth; an increased nasal secretion, sufficient to cause the 
patient to think he has a coryza; some frontal headache from 
congestion of the frontal sinuses; and often an acne-like, papular 
eruption. Sometimes there is an increased flow of tears and 
saliva. 

In patients who are on the verge of hyperthyroidism even 
small doses of an iodide may cause tachycardia and other 
symptoms of hypersecretion of the thyroid gland. 

Chronic Poisoning. — Chronic poisoning, which may occur 
after large doses have been long taken, is shown by thyroid 
atrophy, testicular and probably ovarian atrophy, loss of 
weight, and general disturbed nutrition. 

Treatment of Poisoning. — Acute poisoning will not occur 
from an iodide. Chronic poisoning should be treated by 
stopping the administration of the drug and by every possible 
means of increasing nutrition and strength. The drug will be 
more or less rapidly eliminated without help. If hyperthyroid- 
ism has been caused, that condition should be treated by rest, 
and abstention from meat, coffee, tea, and other stimulants. 

Uses. — As stated, sodium iodide should be, ordinarily, the 
drug of choice, although potassium iodide has long had the 
lead, and is the drug most generally used. 

The use of an iodide in small doses as a stimulant to the 
thyroid gland will be discussed under thyroid. Also its use for 



iodine 393 

diagnostic purposes, to determine whether or not the gland is 
hypersecreting in doubtful cases, will be there discussed. 
Small doses of iodide are frequently needed by many patients 
who are suffering from sub thyroid activity. 

To Modify Sclerosis. — In tertiary syphilis iodide has long 
been used, and generally in enormous doses. Large doses are 
not needed, but ordinary doses seem to prevent sclerosis and 
the formation of gummata, probably by activating the thyroid 
gland, by circulating iodine in the blood, and, perhaps, by 
causing deposited mercury to become soluble and re-circulate 
in the system. Improvement in tertiary syphilis is caused by 
the proper action of an iodide. 

Iodides have been largely used in asthma when there is 
bronchitis, and, when there is expectoration of rice-like particles 
and of Charcot-Leyden crystals, iodides are of great benefit. 
But before asthma is treated by iodides, or coin cidently with 
such treatment, possible reflex and protein poisoning causes of 
the asthma should be sought, and especially should the con- 
dition of the nose be studied; also focal infections should be 
eliminated. 

Iodides have largely been used in various joint affections, 
and some patients have improved under such treatment. 
However, focal causes of the joint trouble should be sought, 
and x-ray pictures of joints should be more frequently taken 
to determine the exact disturbance. In acute joint inflamma- 
tions salicylates are of more value than iodides. In gout 
colchicum and cinchophen are more valuable, and alkalies are 
almost always needed. However, in certain conditions iodides 
in small doses may be of value. 

For arteriosclerosis, iodides have long been used. The 
dose certainly need not be large, and its advantage is probably 
in inhibiting sclerosis through increasing the activity of the 
thyroid gland. In arteriosclerosis and in aneurism caused by 
syphilis an iodide is, of course, good treatment. 

The blood-pressure is sometimes lowered by iodides, and for 
this purpose the dose need not be large; this action may be 
due to an increased vasodilator secretion of the thyroid. 

When exudates, whether in joints, in the pleural cavities, 



394 THE PRINCIPLES OF THERAPEUTICS 

in the pericardium, or on the valves after an endocarditis, are 
not progressively resorbed, iodides are of benefit, perhaps by 
activating the whole system. Again the dose should not be 
large, as large doses will cause more debility and interfere with 
the progress toward health. 

In chronic lead poisoning an iodide in small doses, not 
more than 0.20 Gm. (3 grains) twice a day, will aid in the 
elimination of the lead. Too large doses may precipitate sub- 
acute lead poisoning and lead colic. Such treatment should, 
of course, be combined with good nutrition and with hydro- 
therapeutic or other sweating treatments, to cause elimination 
of the lead. 

Iodides are always contraindicated in tuberculosis. 

IRON 

We cannot live without iron, hence the absence of iron from 
the food and drink will cause anemia, exhaustion, dyspnea and, 
death. The body contains about 3 Gm. of iron, the largest 
part of which is contained in the hemoglobin. One-tenth of the 
hemoglobin is probably destroyed daily and some of it is used by 
the liver to produce the bile pigments. The iron is stored in 
the liver, is given to the blood, goes to the bone marrow and is 
used over again in making hemoglobin. Perhaps 0.01 Gm. of 
iron is sufficient to satisfy the daily iron metabolism, unless 
there is some abnormal destruction of red corpuscles, or there is 
hemorrhage. The food generally contains more than enough 
for the daily need. 

In all anemias iron is helpful, if not curative, but in 
some anemic conditions other treatments are as helpful, and 
hence in most cases it is wise to give other medication with the 
iron. 

Ferri Carbonas Saccharatus. — Saccharated ferrous carbonate 
occurs as a greenish brown powder, has a slightly sweetish 
taste, is slightly soluble in water, and the dose is 0.25 Gm. 
(4 grains). The official Massa Ferri Carbonatis (Vallet's 
Mass) is an old honey mixture, and is not needed. 

The official Pilulce Ferri Carbonatis (Blaud 's Pills) is a very 
much used, and generally a satisfactory, method of giving iron. 



iron 395 

Each pill contains about 0.06 Gm. (1 grain) of the carbonate of 
iron, and the dose is one or two pills three times a day. 

Ferri Phosphas. — Soluble ferric phosphate occurs as bright 
green scales, has a slightly acid taste, and is soluble in water. 
It contains about 12 per cent, of iron, and the dose is 0.25 Gm. 
(4 grains). 

Ferrum Reductum. — Reduced iron occurs as a fine grayish- 
black powder, is tasteless, is not astringent, and is insoluble in 
water. The dose of this very useful preparation of iron is 0.06 
Gm. (1 grain). 

Syrupus Ferri Iodidi. — The syrup of ferrous iodide contains 
about 5 per cent, of iron, and the dose is 1 mil (15 minims). 
This preparation is not as much used as formerly, but is often 
preferred when there is anemia and enlarged glands. It should 
be taken very well diluted. 

Tinctura Ferri Chloridi. — The tincture of ferric chloride is a 
very astringent solution, and the dose is 0.25 mil (4 minims), 
which should be taken very well diluted, preferably after meals. 
It is well administered in syrup of citric acid and water, or in 
freshly prepared lemonade. 

Ferri Sulphas. — Ferrous sulphate occurs as bluish- green 
prisms, has a very styptic taste, is soluble in water, and the dose 
is 0.10 Gm. (ij£ grains). This preparation is too astringent for 
ordinary internal use. 

Liquor Ferri Subsulphatis. — Monsel's solution is used ex- 
ternally as a styptic. 

Administration. — There are many other iron preparations 
but they are not needed, and even all of those mentioned may 
not be needed. There are many organic preparations on 
the market, but an organic iron is no more valuable, and many 
times not as valuable, as an inorganic iron. Too much iron 
is administered; a small dose is all that is needed physiologically, 
and 0.20 Gm. (3 grains) of an iron preparation is generally 
enough for twenty-four hours. Consequently, if the dose of 
iron is small, constipation or other unpleasant symptoms that 
iron may cause will not occur. Occasionally, perhaps by some 
chemical mistake in the body, the iron of the food may be lost 
and not metabolized. In such a case, which may sometimes 



396 THE PRINCIPLES OF THERAPEUTICS 

be the trouble in chlorosis, larger doses of iron may be of value, 
as furnishing something that will control or change the 
abnormal chemical reactions. 

One of the most useful iron preparations is the saccharated 
oxide of iron (Eisenzucker) , which may be obtained in tablets 
representing 3 grains. One or two of these tablets a day is 
sufficient, and it is readily taken by children or any other 
patient. 

Action. — Some solid and some liquid preparations of iron are 
styptic to mucous membranes* and to broken or moist skin. 
Other preparations of iron are astringent only as they tend to 
produce constipation. 

Probably most forms of iron are more or less changed in the 
stomach to a chloride by the action of the hydrochloric acid, 
and, provided the preparation is not irritant or too strong, 
the appetite improves. But little iron from any one dose 
is absorbed and metabolized by the body, most of it passes 
through the intestines and out of the body with the feces as 
sulphides and often tannates. The iron may be absorbed from 
the upper part of the intestine partially as a chloride and par- 
tially as a carbonate. A large part passes on through the intes- 
tines, is changed to a sulphide and renders the feces black. 
The larger part of the absorbed iron is carried by the blood to 
the epithelial cells of the large intestine and is there excreted. 

Iron is probably more or less of a stimulant to the red bone- 
marrow. This is especially true when there is anemia and 
the red cells are diminished in number. If iron is given to a 
patient who is normal, with appetite and nutrition good, with 
blood count sufficient and hemoglobin content perfect, it does 
not seem to cause plethora, i.e., it does not increase the red 
cells or the hemoglobin. On the other hand, if the patient 
is plethoric, the administration of iron is likely to cause fullness 
of the head, perhaps headache, and sometimes hemorrhage, 
especially from the nose. The flow of blood is increased by 
the administration of iron during the menstrual period. 

While most of the systemic iron is excreted through the 
cecum and large intestine, small amounts occur in the urine, in 
the saliva, and in the perspiration. 



iron 397 

Over-action. — Evidence of the over-action of iron is a feeling 
of fullness in the head, headache, constipation, and sometimes 
a tendency to hemorrhage and to profuse menstruation. There 
is no poisoning from iron unless a dose of styptic iron is taken 
into the stomach, and then the only action would be that of 
acute irritation. 

Uses. — Iron as a styptic or astringent is now rarely used, as 
the clots formed are likely to decompose and cause infection, 
unless they are soon carefully removed; this is especially true 
in nose-bleed. Other treatments of hemorrhage are generally 
better. The hemostatic action of iron preparations is due to a 
precipitate of albumin which forms a clot; it is not due to a true 
fibrin coagulation. 

For its astringent action the tincture of iron is an old 

and good treatment for relaxed or inflamed conditions of the 

throat and tonsils, but iodine and silver preparations are now 

generally used. 

TREATMENT OF ANEMIA 

The main condition for which iron is used is anemia, and it 
is useful in all forms, but most efficient when the hemoglobin 
content of the blood corpuscles is low, as in chlorosis. As 
above stated, it does not matter much which preparation of iron 
is given, the body will metabolize most any organic or inorganic 
iron. The dose ordinarily need not be large, and the general 
condition of the patient will almost always improve, unless 
there is some serious repeated destruction of the red corpuscles. 
The most deadly destructive organism for red corpuscles is the 
streptococcus hemolyticus , which is so frequently present in 
acute infections, and is so often present in the disease that 
causes the greatest number of deaths at the present time, 
namely, pneumonia. 

Not every patient who is pale is anemic; not every patient 
who has no appetite and whose nutrition is low needs iron. On 
the other hand, the great majority of patients who are run down, 
or who are convalescing from some serious disease, are anemic, 
and do need iron; but very frequently an increased amount of 
meat or of vegetables that carry large amounts of iron, as greens, 
will soon improve the anemia. 



39S THE PRINCIPLES OF THERAPEUTICS 

Symptoms of anemia, besides the positive finding of a low 
blood count and a low hemoglobin content, are dyspnea, pale- 
ness of the face, especially pale gums, bluish sclerotics, and in 
women, amenorrhea. Anemic patients often suffer from neu- 
ralgias, which are cured by the administration of iron. 

Whatever the kind of anemia present its cause should be 
sought, and no matter of how much benefit the administration of 
iron may be, the anemia will recur unless the cause is removed. 
Besides the more serious diseased conditions, as tuberculosis, 
cancer, and actual hemorrhage (as from hemorrhoids, gastro- 
intestinal ulcers, too profuse menstruation, etc.) chronic sup- 
puration is a frequent cause, as are also focal infections and 
albuminuria. 

TO INCREASE THE URIC ACID EXCRETION 
PHENYLCINCHONINIC ACID 

ClNCHOPHEN. ATOPHAN 

This drug occurs in small needles or as a white or yellowish 
powder, insoluble in water, and the dose is 0.30 Gm. (5 grains). 

At the present time this is the most active drug we possess 
to cause an increase in the uric acid output. It is a stimulant 
to the kidneys, increases the amount of urine, and under its 
action the uric acid of the blood is decreased in amount. 

From the action of cinchophen the urine may contain such 
a large amount of uric acid crystals that severe irritation and 
even renal colic is caused. Consequently,the amount of the 
drug given should not be as large as formerly used, and 0.30 Gm. 
(5 grains) is a large enough dose, given two or three times a day. 
At the same time, the patient should take an alkali, best the 
bicarbonate of sodium. 

Cinchophen may quiet the pain of acute gout and sometimes 
acts very satisfactorily in other forms of joint pains. 



PART IV 
THE ENDOCRINE GLANDS AND ORGANOTHERAPY 

Preparations of the Endocrine Glands. — (a.) Those that have 
recognized positive therapeutic value. — Thyroid; parathyroid; 
pituitary; suprarenal; corpus luteum. 

(b) Those that have therapeutic value but not as evident, 
hence not as generally accepted. — Ovaries, placenta; mammary; 
testicles; thymus; pineal. 

(c) Glandular tissues that have important functions, but 
whose extracts have not been shown to have therapeutic value 
other than that of foods or digestants. — Pancreas; spleen; 
secretin; liver; kidneys; parotid; prostate; lymph glands; brain; 
meat extracts; nuclein. 

GENERAL CONSIDERATIONS 

To understand both the rational and the experimental thera- 
peutic uses of endocrine gland preparations the clinician must 
note the normal functions of these glands and the symptoms and 
signs of their dysfunction. Hence to decide that one or more 
endocrine glands are abnormal the clinician must know the 
physiology and pathology of these glands as far as laboratory, 
clinical and post-mortem experience has developed. 

To determine the physiologic condition of these glands in 
an individual one must learn to study the patient and his 
previous history with the object of developing a picture that will 
show normal or abnormal endocrine gland activities. Toward 
that end details of the physical condition and previous develop- 
ment of the individual, as well as details of his habits, mental 
attitude and general mentality must be ascertained and out- 
lined. A careful study of the activities of the endocrine glands 
is very profitable for both physician and patient, as the right 
treatment for the cure of his abnormal condition may thus be 
made evident. Such a careful study of patients will not only 

399 



400 THE PRINCIPLES OF THERAPEUTICS 

show gross types of hyper- and hypo-secretions of the different 
endocrine glands, but will also discover signs of slightly increased 
or slightly diminished secretions. 

The lines of investigation may be suggested as follows: 

Sex; age; size; general build. 

General characteristics of the family; family history. 
Babyhood: rate of growth; babyhood food; eruption of teeth. 
Childhood: rate of growth; character of food preferred; fat 

deposits; ability to study and learn; likes and dislikes of 

work, play and amusements; age of development of secondary 

sexual characteristics. 
Age of puberty: growth of hair, axillary and pubic; in the male, 

date of change of voice and growth of beard; in the female, 

date of beginning of menstruation and development of the 

mammary glands. 
Adult: social life; temperament; temper; food best liked; food 

cravings; digestive disturbances; urinary peculiarities; habit 

of perspiration; sexual life. 
Physical examination: note mentality; build of body, head, 

trunk, legs; fat deposits; facial type; spacing of eye-brows; 

external genitals. 
Skin: texture; sensations; pigmentation; hair. 
Mouth: arch of palate; spacing of teeth; tonsils; adenoids. 
Glands: thyroid; mammary; thymus; lymph glands. 

It should be recognized that when one gland is mal-function- 
ing others are also disturbed and may thus cause atypical 
conditions. 

Under the discussions of the various endocrine gland activi- 
ties the types of disturbances caused by their mal-function will 
be described, but a few indications of endocrine disturbances 
are here mentioned. However, the student is urged to refer to 
books on endocrinology for detailed descriptions of endocrine 
pathology. 

With good thyroid activity the teeth are generally white and 
well formed. If the thymus, and perhaps the parathyroids, are 
insufficient, calcium nutrition may be disturbed, and the teeth 
show pitting and imperfect enamel. If the anterior pituitary 



THE ENDOCRINE GLANDS 401 

hypersecretes, the teeth are likely to be wide spaced. Pigmen- 
tations on the teeth as pigmentations everywhere, on the skin and 
mucous membranes, show cortical disturbance of the adrenals. 
Large canine teeth seem to be associated with increased 
adrenal secretion, and normal sized lateral incisors show normal 
gonads. 

Many of the endocrine glands take part in the production of 
hair, more especially the thyroid, the adrenals and the gonads. 
The thyroid seems to have a special function in controlling the 
amount of hair on the scalp and upper parts of the body, and 
also determines the character of the eye-brows. When the 
thyroid subsecretes there is a diminished amount of hair 
development, the hair falls out, or it does not grow normally 
on the body. When this gland is only mildly insufficient the 
eye-brows are very thin, while when the eye-brows are heavy 
and meet at the bridge of the nose there is increased adrenal 
secretion. Cretins generally have a normal or increased 
amount of hair on their heads, although a myxedematous 
patient may have entirely lost the hair from the scalp. In- 
creased thyroid secretion may sometimes show lessened hair 
development and sometimes an increased hair development, 
the variations probably due to associated other glandular 
disturbances, as increased adrenal secretion always increases 
the growth of hair on the body. Coarse hair is due to increased 
adrenal secretion, and Kaplan states that abnormally colored 
hair, as blond hair in a Spaniard and black hair in a Swede, is 
due to disturbed adrenal secretion. Also he states that the 
majority of red-haired individuals have increased adrenal 
secretion. 

The ovaries and testicles seem to control the amount of pubic 
and axillary hair, while the testicular secretion also seems to 
cause the growth of hair on the face, i.e., the beard and mustache. 
In testicular insufficiency there may be very little hair on the 
body yet a good deal on the head, and eunuchs have a large 
growth of hair on the scalp. A growth of hair on the face in 
females is generally due to ovarian disturbance, and at the 
menopause many women have hair develop on the chin. In 
pituitary disturbances there may be patches of hair as well as 

26 



402 THE PRINCIPLES OF THERAPEUTICS 

warty growths appear on different parts of the body, arms and 
legs. 

A soft, fat skin is typical of insufficient post-pituitary secre- 
tion; a thin, soft skin of hyperthyroid secretion; a thick, dry- 
skin of hypothyroid secretion. Freckles, brown spots and dark 
skin show adrenal disturbances. Hot flashes, blushing, and 
dilatation of the peripheral blood-vessels are typical of hyper- 
thyroidism, and individuals who suffer from this condition are 
always too warm, and object to hot weather. In sub-thyroid 
conditions the skin is pale, rarely flushes, and the individuals 
feel, the cold and dislike it. 

Hypersecretion of the adrenals makes the individual muscu- 
larly strong. Insufficiency of the thyroid and of the anterior 
pituitary ^stunts growth and makes a dwarf, while hypersecre- 
tion of the anterior pituitary causes giant growth, and abnormal 
secretion of the pituitary will cause acromegaly. Increased but 
normal secretion of the pituitary gland in the male (which 
gland seems, to be typically a gland of more importance for the 
female) produces a tendency to femininity. An increased 
secretion of the adrenals in the female (and these glands seem to 
be of more importance to males than to females) tends toward 
masculinity. Insufficiency of the gonads causes various forms 
of infantilism, and if the testicles are insufficient the man 
becomes effeminate, and if the ovaries are insufficient the 
woman becomes masculine. Hyposecretion of the thyroid, 
of the post-pituitary, and of the adrenals tends to cause obesity 
and deposits of fat. 

Disturbances of the internal secretions in childhood and before 
puberty may cause the relation of the length of the body to the 
legs to be abnormal. Disturbances of the thymus gland and of 
the pituitary as well as of the gonads may cause such abnormal 
relationships. An early development of the menstrual function 
will cause the girl's legs to be short and the general growth is 
stopped, while a late development of this function allows growth 
to be continued and the legs become long. 

The relationship of the endocrine secretions to mental types 
and mental conditions is not sufficiently recognized. Some 
individuals are well balanced, perfectly normal, and react nor- 



THE ENDOCRINE GLANDS 403 

mally to every mental impression. Such individuals have 
normal endocrine glands. Other individuals are neurotic or 
unbalanced, are tempermental, moody, and " queer" because 
they have inherited or acquired deficient or abnormal endocrine 
glands. Some individuals have malicious instincts because of 
such disturbances, and other individuals deserve no credit for 
perpetual good behavior because the glands that furnish im- 
pulses are insufficient. 

It is also not recognized that many headaches are due not 
only to presistent enlargement of the pituitary, but to tem- 
porary enlargement of this gland and to its hypersecretion. 
This headache typically occurs in women before or during the 
early part of menstruation. The headache may be described 
as back of the eyes, or referred to the temporal region, or to the 
top of the head. 

While on the subject of disturbances caused by insufficiency 
of glands it may be well to note that some careful observers be- 
lieve that the consequences of completely removing tonsils may 
be serious. There may be disturbances of the blood and of the 
circulation, and persistent headache has been noted, and it has 
even been suggested that hypertrophy of the appendix and 
chronic appendicitis have resulted from extirpation of the tonsils. 
Undoubtedly too many tonsils have been removed, but nothing 
in the above findings or consequences should prevent the ex- 
tirpation of totally diseased tonsils or the extirpation of diseased 
portions of tonsils, but it should be declared that only obstruc- 
tive portions of healthy tonsils should be removed, and perhaps 
rarely need both tonsils be totally extirpated. 

Insanity. — The relationship of mental disturbances to the 
endocrine glands is being more and more carefully studied, and 
it is especially important to determine what causes abnormal 
mental conditions in boys and girls. In a recent article by 
Sajous he states that statistics show that thirty thousand of our 
boys and girls are sent to insane asylums each year, to remain 
there until they die, on account of dementia praecox, which form 
of insanity represents 53 per cent, of our asylum inmates. 

In the first place, in all cases of insanity focal infections, 
especially of the mouth and tonsils, should be sought, and, if 



404 THE PRINCIPLES OF THERAPEUTICS 

present, eliminated. In the next place, it should be determined 
whether or not the thymus gland is enlarged, and Sajous believes 
that the thymus plays some part in causing this disease. 

Prior 1 presents the statistics of forty-six post-mortem exami- 
nations of mental cases in which twenty-five had a definite thy- 
mus gland. Of these forty-six, thirty-two were epileptics and 
twenty-two of these had a persistent thymus. The largest 
glands were found in epileptics and eight epileptics died sud- 
denly, and all of these had enlarged thymus glands. There was, 
also, in many of these patients degeneration of the suprarenal 
cortex. 

It is especially interesting to note the important part the 
thymus gland seems to play in the early life of children, and 
Sajous finds that the thymus has been absent in more than 50 
per cent, of young idiots and mentally defective children. 
Hence it probably is subnormally secreting in children who are 
partially mentally defective. 

Sajous thinks that an efficient thymus aids the ductless 
glands in general in preventing toxic irritants reaching the brain, 
hence its deficiency allows such irritations to occur, and he 
suggests that insufficient nucleins or some mal-chemical com- 
binations due to poor functioning or to early decreased thymus 
function may be the cause of dementia prascox. Perhaps there 
is a phosphorus disturbance. 

In many forms of insanity other ductless glands play an im- 
portant part. Hyperactivity of the thyroid is known to cause 
serious mental excitement, at times even mania, while a sub- 
thyroid secretion tends to produce melancholic types. Para- 
thyroid disturbances are known to cause a condition bordering 
on spasmophilia and to cause tetany, and parathyroid and thy- 
roid disturbances not unlikely have a relation to epilepsy, and 
the thymus is persistent and enlarged in some forms of epilepsy. 

The adrenal glands have been found disturbed in some types 
of insanity. Adrenal insufficiency causes mental depression, 
even melancholia, perhaps due to low blood-pressure and poor 
circulation in the brain. 

The effect of pituitary disturbance on the brain is perhaps 

1 Journal of Mental Science, London, Jan., 1920, p. 23. 



THE ENDOCRINE GLANDS 405 

more or less due to pressure symptoms, as all kinds of mental 
disturbances can occur in acromegaly, in which condition this 
gland is enlarged or diseased. 

Diseased ovaries have seemed at times to cause mental dis- 
turbance, and operations on the ovaries and on the thyroid 
glands have sometimes cured such conditions. 

The neurotic individual is such because of thyroid hypersecre- 
tion, but a neurotic child may have several disturbed endocrine 
glands, and the patient should be very carefully studied to de- 
cide just what is causing the trouble. 

Vasomotor Disturbances. — If a patient has evident exter- 
nal symptoms of Raynaud's disease and spasm of the blood- 
vessels, many undiagnosed internal conditions may be due to 
the same sort of blood-vessel spasm. Severe abdominal pains 
for which operations have been done and no disease found, may 
be due to spasm of some blood-vessel in the abdomen. Fainting 
attacks, semi-paralytic attacks, queer headjattacks, and petit 
mal and epileptic attacks may be due to the same arterial 
spasm of some blood-vessels of the brain. Also, when there are 
angioneurotic edemas externally, there may be smaller disturb- 
ing edemas internally causing conditions that cannot be diag- 
nosed. Consequently, when the cause of an internal distur- 
bance is not readily understood, a study of the endocrine gland 
conditions should be made. 

For quick reference the following list of disturbances of the 
endocrine glands will be useful, although it should be recognized 
that associated disturbances of several endocrine glands will 
cause atypical signs and symptoms. 

1. Thyroid absent = a cretin. 

2. Pineal disturbance = precocious sexuality. 

3. Thymus insufficiency = too early sexuality. 

4. Thymus too long active = delayed puberty. 

5. Pituitary hypersecretion = a giant. 

6. Pituitary posterior hyposecretion \ = wth a fat chiM 
Pituitary anterior hypersecretion J 

7. Thyroid subsecretion = slow growth; poor mentality; obesity. 

8. Suprarenal hypersecretion = early maturity; mentally active; physically 
active; if a female = masculinity. 

9. Suprarenal hyposecretion = general weakness; non-aggressive mentality; 
if a male = femininity. 



406 THE PRINCIPLES OF THERAPEUTICS 

10. Gonads hypersecretion = sexual perversity. 

Gonads hyposecretion = sexual insufficiency; obesity. 
ii. Thyroid hypersecretion = Graves' disease. 

Thyroid hyposecretion = many types of abnormal conditions. 

Teeth 

i. Thyroid normal = good white teeth. 

2. Pituitary hypersecretion = large incisors, separated. 

3. Gonad hyposecretion = small lateral incisors. 

4. Suprarenal hypersecretion = sharp, long canines. 

Haer 

1. Thyroid normal = fine hair; normal growth. 

2. Thyroid hyposecretion = loss of hair. 

3. Suprarenal hypersecretion = hairy; eye-brows heavy and meet. 

4. Suprarenal hyposecretion = scanty hair; moles and pigmented spots. 

5. Pituitary hypersecretion = hairy. 

The following discussion of the activities and therapeutic uses 
of the endocrine glands represents the best consensus of opinion 
at this date. The text is derived from a careful study of the 
literature combined with the writer's own long clinical studies 
of the action and use of the organ extracts and a personal study 
of very many cases of endocrine disturbances. It should be 
recognized that the rapid development of new data concerning 
the physiology and chemistry of these glands may make parts 
of this discussion at any momentobsolete. 

Endocrine Glands that have Positive Therapeutic 

Value 

thyroid gland 

Physiology. — Although the thyroid gland weighs only about 
one ounce, it is estimated that, with a normal rapidity of the heart, 
all of the blood of the body passes through the gland about once 
an hour. If the blood-vessels of the thyroid are enlarged, or if 
the heart acts more rapidly, theoretically the blood of the body 
would pass through the thyroid much more frequently than 
once an hour, and even with a normal thyroid secretion the blood 
could take up more of it than is necessary for health. 

There may be small supernumerary thyroids, and there may 
be an intrathoracic thyroid. Fetal thyroids are relatively larger 



THYROID GLAND 407 

and contain relatively more iodine than adult glands. Females 
have more thyroid tissue and consequently normally more iodine 
than males. Some drugs increase the activity of this gland, 
notably strychnine and caffeine, hence tea and coffee are stimu- 
lant to it. Animal proteins increase its activity. Quinine in 
large doses and morphine diminish thyroid activity. Privation 
of milk and vegetables and drinking a very soft water, as rain 
water, may cause not only calcium deficiency but thyroid 
disturbance. 

Normal function of the thyroid promotes the normal skeletal 
growth of children; diminished function inhibits such growth. 
Good thyroid activity causes the growth and development of 
perfect teeth, both as to color and spacing. 

The thyroid normally enlarges and hypersecretes during 
pregnancy. If it does not do so, the teeth of the pregnant woman 
decay, her nails become brittle, and she loses some of her 
hair; i.e., she shows signs of too much loss of calcium, her re- 
serve being used for the growth of her child. She then shows 
the need both for more iodine to properly stimulate the thyroid, 
and for more calcium. Insufficient thyroid secretion in the 
pregnant woman may cause an enlarged thyroid in the child at 
birth, or the child may have an insufficient thyroid. 

If the thyroid does not hypertrophy in pregnancy there is a 
tendency to toxemia in the mother and to imperfect develop- 
ment of her child. If the mother has sub thyroid secretion 
after the child is born, she should not nurse her child, unless she 
is given thyroid extract, or the child is given it. Often, also 
her milk may not be sufficient in other qualities for the welfare 
of the child. It may not contain the normal amount of vita- 
mines. A child's brain does not well develop, if the thyroid 
secretion is insufficient. 

The thyroid seems to have a close relation to the pancreas, 
and its secretion is perhaps inhibitive to hyper-functioning of 
the pancreas, as when the thyroid subsecretes the pancreas 
often over-secretes and glycosuria results. On the other hand, 
in cretins and in myxedema the blood sugar is often decreased. 
There is also a tolerance for sugar, and often a great desire for 
it. All metabolism is slowed in subsecretion of the thyroid, 



408 THE PRINCIPLES OF THERAPEUTICS 

and fat is deposited, perhaps due to a disturbed carbohydrate 
function. 

One of the most important activities of the thyroid is its 
ability to prevent poisoning of the body, especially the poison- 
ing that occurs from acute or chronic infection. If the thyroid 
is insufficient or becomes insufficient from such poisoning or 
irritation, life is endangered, and the patient is benefited by 
the administration of iodine or thyroid extract. In thyroid 
insufficiency there are more or less poisonous substances cir- 
culating in the blood. The seriousness of chronic focal infec- 
tion, either of the mouth or tonsils, in causing primarily enlarge- 
ment of the thyroid and secondarily insufficiency of the thyroid, 
should be recognized. On the other hand, such an infection 
often causes the thyroid to hypersecrete, and Graves' disease 
develops, hence a focal infection as the probable cause should 
be sought. If the thyroid under-secretes, the danger may 
not be recognized, but the patient is more likely to succumb to, 
or to be seriously affected by, any acute disease that attacks 
him. With mouth infections, and the streptococcus viridans 
as the infecting agent, it may be for a time difficult to tell 
whether the irritated thyroid or the germ is the cause of the 
cardiac symptoms. Both causes may be active at the same 
time. 

An enlarged thyroid is frequently an evidence that it is 
trying to overcome a chronic toxemia. Therefore many times 
the thyroid is supposed to be at fault when it really is doing 
its best to overcome some other condition that needs treatment. 
An individual who has survived many infections and serious 
conditions in all probability has a very normal thyroid. When 
the thyroid is hypersecreting it may cause serious cerebral 
disturbance by its ability to break down the phosphorized 
fats. 

If there is too much thyroid secretion, or if thyroid extract 
is given a child when it is not needed, there will be an early 
development of the secondary sexual characteristics and an 
early maturity. If a child does not grow, such slow growth 
not being due to thyroid insufficiency, thyroid feeding will 
not increase the growth and may even retard it. 



THYROID GLAND 409 

If the thymus secretion is insufficient in childhood, and 
thymus gland is administered, a too early maturity will be 
prevented; but, if the thymus is sufficient and thymus gland is 
fed, the general growth may be increased but secondary sexual 
characteristics and maturity will be postponed. Too much 
thyroid secretion soon after puberty in girls may cause them 
to be immoral. 

In Graves' disease there is a diminished tolerance to carbo- 
hydrates, perhaps due to an increased secretion from the 
posterior lobe of the pituitary, or due to pancreatic disturbance, 
or to liver irritation, . or perhaps due to all of these factors, 
hence glycosuria is frequently a symptom. Also, feeding large 
doses of thyroid extract may cause glycosuria. 

Feeding of thyroid to married women tends to allow preg- 
nancy to occur. This is especially true in sub-thyroid cases, 
even when there has long been sterility. 

One of the chief functions of the thyroid is to take iodine 
from the blood and store it to form its active substance, thyrox- 
in. If the thyroid cannot do its work, the pituitary may 
assume some of the thyroid activity. In certain forms of 
thyroid insufficiency and in certain forms of enlargement of the 
thyroid, iodine in small doses, or an iodide in small doses, may 
cause the gland to return to normal. 

In endemic goiter there is likely to be a diminished amount 
of iodine in the thyroid and retention of calcium in the body. 
In toxic goiter, there is likely to be a large amount of iodine 
in the thyroid, and calcium is rapidly lost from the body. 

Feeding of iodine may change an enlarged hyperplastic 
thyroid to one of the colloid type. In hyperthyroidism calcium 
should be given both with the food (milk) and as a drug, and 
calcium deficiency, either from an increased loss, or from lack 
of it in the food, is the cause of some of the symptoms of 
hyperthyroidism. Starvation seems to reduce the size of the 
thyroid and to decrease its normal activity. Therefore it is 
important when there is serious vomiting, or for any reason 
the patient cannot receive food, that small doses of iodine 
should be given in some manner, perhaps by allowing iodine 
to evaporate in the room. 



4IO THE PRINCIPLES OF THERAPEUTICS 

While thyroid tissue can be planted and live for a time, it 
is absorbed, but until such absorption has taken place, it 
may ameliorate the symptoms caused by the absence of thy- 
roid secretion. By the time the graft has absorbed, in some 
patients the portion of the gland left after operation, or super- 
numerary glands, may have become enlarged and furnish suffi- 
cient secretion. 

Thyroid substance given by the mouth is not injured by 
digestion, and it not only causes thyroid activity, but increases 
the amount of urine and the nitrogen output, especially in 
nephritis. If there is a need for thyroid, small doses will not 
cause loss of weight, and may even cause a gain of weight, al- 
though large doses long continued will always cause a loss of 
weight. 

In hyperthyroidism the blood is less coagulable, which may be 
due perhaps to the coincident extra loss of calcium from the 
body. There is much more tendency to hemorrhage in hyper- 
thyroidism than in normal thyroid activity, and in hypothy- 
roidism the blood generally coagulates more rapidly than in 
hyperthyroidism. 

If the thyroid gland is removed, the hypophysis, both anterior 
lobe and pars intermedia, become enlarged, showing some 
cooperative function of these two glands; and in acromegaly, 
which is due to pituitary disease, the thyroid is hypertrophied. 

There has been shown to be a greatly increased basal metab- 
olism, even to 80 per cent, in Graves' disease, and a greatly 
diminished basal metabolism, even to 40 per cent, in myxedema. 
This shows the necessity for normal thyroid secretion for normal 
metabolism. Recent statistics of examination of men recruited 
for the army in this country have shown an enormous number of 
enlarged thyroid glands, and in a considerable number of these 
cases the glands were notably enlarged. While a good many 
of these men may have come from districts where there is 
endemic goiter, unfortunately it was not noted, and therefore 
we have not sufficient data to show, how frequently with these 
enlarged glands there was mouth or tonsil infection. Probably 
there was such infection in a large percentage of the cases. 

There are various types of enlargement of the thyroid gland: 



THYROID GLAND 411 

normal hypertrophy; colloid growth; cystic degeneration; con- 
nective tissue enlargement; sometimes acute inflammation and 
abscesses; and rarely cancer and sarcoma. 

To briefly sum up the activities of the thyroid gland, it may 
be stated that its secretion is necessary for the proper skeletal 
growth of the child and for its mental development, and it is 
necessary for the proper mental health of the adult. Its secre- 
tion is necessary for the proper growth and health of the teeth, 
hair, and nails, and for the proper menstrual and maternal 
functions of women. It is necessary for normal nitrogenous 
metabolism of the body, for normal carbohydrate function, and 
for the normal amount of fat deposits in the body. Its secretion 
is necessary to prevent poisoning from disturbances of the nitrog- 
enous metabolism, and perhaps from disturbances of fat metab- 
olism. It is a de toxicant, and prevents toxic symptoms from 
toxins circulating in the blood from acute and chronic infection. 

This gland is present at birth, and functions throughout 
childhood, has an increased function at puberty, and continues 
its increased activity to about the age of iorty-five, from which 
time onward it gradually decreases its activity, and more or 
less atrophies in old age. It acquires and stores iodine, and 
produces the active principle termed thyroxin, which is so 
necessary as an activator for all parts of the body, and which 
will be described under the heading of chemistry of this gland. 
It also furnishes a substance that is a vasodilator, and this 
gland may coordinate with the glands furnishing vasopressor 
stuff, and, in conjunction with the vasomotor center, may assist 
in regulating the circulatory blood-pressure. Its secretion is a 
distinct stimulant to the heart, and its increased secretion causes 
tachycardia. 

There is likely to be an abnormal condition of the blood when 
there is a disturbance of the thyroid secretion, showing that it 
is more or less essential for the normal production of normal 
blood. 

Men and animals may live after the thyroid gland has been 
removed, provided the parathyroids are not extirpated. Sooner 
or later, however, disturbances occur which will lead to greatly 
impaired health, if not to death, unless thyroid extract is fed. 



412 THE PRINCIPLES OF THERAPEUTICS 

Hoskins and Hoskins 1 came to the conclusion from their own 
investigations and those of others with amphibian larvae that 
"removal of the thyroid hastens their growth but causes hyper- 
plasia of the hypophysis and prevents metamorphosis; that 
removal of the hypophysis retards general growth, retards the 
development of the thyroid, prevents metamorphosis, and re- 
tards development of the cutaneous pigment; that feeding 
thyroid or hypophysis (or iodine) to normal larvae hastens 
metamorphosis; that feeding thyroid or hypophysis (or iodine) 
to thyroidectomized larvae brings about metamorphosis, that 
feeding hypophysis to hypophysectomized larvae stimulates 
growth but does not cause metamorphosis; that feeding iodine 
to larvae with both the thyroid and hypophysis removed causes 
metamorphosis. " 

Chemistry. — One of the most interesting chemical studies of 
the body is the need of the thyroid gland for iodine to render 
its secretion active. It has been known for many years that 
iodine was present in the thyroid gland, and that the substance 
which was combined with iodine was an active one in maintain- 
ing health, and that an over-amount of it would cause the 
symptoms recognized as those of hypersecretion of the thyroid. 

The average iodine content of a normal thyroid gland is 
0.0025 Gm., while in the colloid thyroid gland there is only 
0.0015 Gm., and in the hypertrophied gland 0.0005 Gm., per 
gram of the dried gland. 

Kendall has recently shown by great refinement of chemical 
determinations, that there is approximately 0.015 milligram of 
iodine per hundred c.c. of blood, while the iodine content in 
tissues is about 0.03 milligram per hundred grams, and in the 
liver about 0.04 milligram per hundred grams of that tissue, 
while the substance which he has named " thyroxin" contains 
about 60 per cent, of iodine. 

The older the patient generally the less iodine the gland 
contains, and many times the more the hyperplasia of the 
thyroid, the less the iodine, and in typical exophthalmic goiter 
the gland may contain only a small percentage of the total 
amount of iodine contained in a normal gland. However, 

1 Endocrinology, Jan.-March, 1920, p. 1. 



THYROID GLAND 413 

generally in Graves' disease the administration of iodine in- 
creases the hyperthyroidism symptoms. It has long been 
shown that there are great variations in the amount of iodine in 
the glands of animals in different seasons. 

Fenger 1 found no more phosphatids in thyroid than in other 
lean meat, though the phosphatids are increased in the pituitary, 
suprarenal, pineal, the infant thymus, and in the corpus luteum 
of pregnancy, as compared with muscle tissue. 

Kendall first isolated the chemical entity which he terms 
thyroxin in 1914. Since that date, in the Rochester Labora- 
tories, about $2> grams of this substance have been separated 
from more than three tons of fresh thyroid material. It has 
been found possible to synthetize this most active substance. 

In 1 91 5 Kendall 2 described his two groups of thyroid pro- 
teins. Group A he named the acid insoluble compounds, and 
group B the acid soluble compounds. From group A he isolated 
a pure crystalline compound containing 60 per cent, of iodine. 
Group B contains iodine in some unknown form of combination. 
It is a mixture containing amino acid complexes. Kendall, 
later, called this iodine crystalline extract " thyro-oxy-indol, " 
or " thyroxin," and this is the energy factor of the thyroid, and, 
as he states, the generator of the rate with which we live. 
According to Plummer, normally, there is about 0.013 Gm. of 
this energy stuff in the body, and each increases of about 0.033 
milligrams of thyroxin in the body increases the energy output 
1 per cent. Hence the energy of the body varies with the 
amount of thyroxin, and Graves' disease may increase this 
energy even to 100 per cent. Plummer states that the thyroid 
secretion persists in the body for about eighteen days. The 
size of the thyroid gland is no clue to its activity, as has long 
been known, and large colloid deposits are more or less inert as 
far as furnishing energy or activity is concerned. 

Kendall 3 stated that injections of amino acids may cause 
polyuria, normal or high temperature, good or fast pulse, in- 
creased sensitiveness of touch, tremor, twitching, and tetany, 

1 Journal of Biological Chemistry, Nov., 1916. 

2 Journal A. M. A., June 19, 1915, p. 2042. 

3 Journal A. M.' A., Aug. 25, 1917, p. 612. 



414 THE PRINCIPLES OF THERAPEUTICS 

and the autopsies will show very hyperemic intestines, suprare- 
nals, thymus, and pituitary. Or such an injection may cause a 
diminished amount of urine, low temperature, slow pulse, 
sluggishness, and stupor. He found that a starved animal will 
show the former symptoms, and an animal who has been fed 
plenty of meat will show the latter symptoms. He believes the 
former condition is caused by piling up of pre-urea stuff, which 
he terms "X, " from an excited (active) cortex of the suprarenals. 
The latter symptoms are caused by the piling up of ammonia 
in the blood. Hyperactivity of the thyroid is generally accom- 
panied by hyperactivity of the suprarenal cortex. 

Kendall 1 describes the physiologic activity of thyroxin as 
follows: when injected subcutaneously into animals there is at 
first no effect on either the pulse-rate or the blood-pressure, 
but after twenty-four to thirty-six hours the animal appears 
restless, there is a slight increase in temperature, and a decided 
increase in pulse-rate, and if several injections are given on 
successive days, these symptoms are all aggravated. He 
found_that successive daily administration of thyroxin causes 
death, while a single injection of an enormous dose produces, 
in most instances, no effect. Therefore he concludes that 
thyroxin itself is not toxic, but toxic effects are caused by 
changes of this substance in the body when a dose is repeated 
and the thyroxin itself cannot be utilized. In other words, 
although an intravenous injection of thyroxin may produce 
no changes in the blood-pressure, pulse-rate or nervous system, 
or any of the so-called hyperthyroid symptoms, the long 
continued presence of thyroxin itself in the tissues of the 
body produces the picture of hyperthyroidism in its entirety, 
terminating in emaciation and death. He found that when 
a large single dose of thyroxin was injected into the vein of a 
dog, about 43 per cent, of the iodine contained in the thyroxin 
was excreted in the bile in fifty hours, and 13 per cent, by the 
urine in the same time. Probably the remainder of the iodine 
was retained by the thyroid gland, and as Marine and others 
have shown that the thyroid absorbs iodine from the blood, 
it probably may also absorb thyroxin. 

1 Endocrinology, April- June, 19 19, p. 156. 



THYROID GLAND 415 

If a large dose of thyroxin is several times repeated, the 
excretion by the bile and by the urine, and the storing by the 
thyroid may be so disturbed that the tissues receive more 
thyroxin than they can handle, and their energy is increased, 
and the symptoms of toxemia occur. 

Plummer finds that the physiologic effects of a single dose 
of thyroxin is greatly delayed in man, but the duration of the 
effect is exceedingly long, and he finds that the maximum effect 
from a single injection in a myxedematous patient is not reached 
until the tenth day, and it may be three weeks before a single 
dose has ceased to function. He also finds that o.ooi Gm. of 
thyroxin in an adult weighing 150 pounds increases the meta- 
bolic rate 2 per cent. Myxedematous patients have their 
metabolic rate 40 per cent, below normal, on account of the 
absence of thyroxin. Such privation does not cause death, but 
their metabolic activities are all at a minimum, and their func- 
tions cannot be normal without the administration of thyroxin. 

Kendall says that "the amount of thyroxin within the tissues 
is undoubtedly a physiologic constant, a figure as constant per 
weight of tissue as the normal number of red cells per cubic 
millimeter of blood." 

It would seem probable that while a certain amount of 
thyroxin is necessary to circulate in the blood to activate the 
tissues to a proper amount of energy, there must be some 
mechanism whereby that energy could be increased, if called 
for, by perhaps more thyroxin being produced, or by the 
removal of stored thyroxin. 

Seidell and Fenger 1 and Fenger 2 have shown that in the 
winter months the thyroid glands of beef, sheep and hogs all 
contain less iodine than during the summer months. To keep 
up the body temperature during the winter months the animals 
require more energy, and, hence, probably draw thyroxin from 
the thyroid gland, where perhaps it has been stored during the 
summer months. 

Pathology. — The thyroid gland may be enlarged by hyper- 
trophy, or enlarged by the increase in colloid ; it may be cystic, 

1 Journal of Biological Chemistry, 191 2-13. 

2 Endocrinology, 1918, No. 2, p. 98. 



41 6 THE PRINCIPLES OF THERAPEUTICS 

adenomatous, and rarely cancerous; and it may be atrophied. 
That the thyroid gland is enlarged is no indication that it is 
hypersecreting, and on the other hand, it may hypersecrete 
and yet not be enlarged. Its activity may be increased to 
fight some infection, and later it may become enlarged on 
account of this increased activity. 

It is not purposed here to describe all of the pathologic 
conditions of the thyroid gland, but an enlarged thyroid in 
children and young adults is likely to be hyposecreting, and 
generally calls for iodine. Physiologically the gland enlarges 
with menstruation and with pregnancy. It also probably is 
extra active in the first stages of, and perhaps during, acute 
infection, and if that infection is severe and lasts for some time, 
the thyroid may deteriorate and become less active later. 
Long continued irritation, especially nervous irritation, often 
causes hypersecretion and perhaps later a toxic goiter. 

It has recently been shown that goiters, in young girls 
just before puberty, may be prevented, provided they receive 
a small amount of iodine. It seems to be immaterial 
whether they inhale this iodine from vaporizing iodine in 
the schoolroom or in their bedrooms, or whether they receive 
a small amount of iodine daily as a medicine, for success in 
preventing this kind of enlargement of this gland. An ounce 
of an ordinary tincture of iodine kept in a large mouthed open 
bottle will gradually vaporize in the room and may last for 
a month. Also satisfactory in preventing goiter in youth 
is the administration of about 2 Gm. (30 grains) of sodium 
iodide in 0.20 Gm. doses for ten days or 0.10 Gm. doses for 
twenty days, and this dosage repeated two or three times a 
year. When iodine is administered to young girls who have 
an enlarged thyroid gland without toxic symptoms, 0.05 Gm., 
or even less, of sodium iodide once a day is sufficient. This 
dose may be continued for many weeks. 

While all disturbances of the thyroid gland were considered 
very much more frequent in women than in men, and it was 
stated that 80 per cent, of the cases occurred in women, at the 
present time this percentage is not true. Probably now 60 per 
cent, of all cases occur in women and 40 per cent, in men, al- 



THYROID GLAND 417 

though the more serious symptoms of both hyperthyroidism and 
hypothyroidism do occur in women in the majority of instances. 
Thyroid disturbance has become more frequent in men, owing 
largely to mouth infection from crowns, bridges and dead teeth. 
Possibly some of the thyroid disturbance in young men is due 
to excessive athletics. A goodly number of the so-called neuro- 
circulatory asthenia cases, especially of drafted men, is due to 
hyperthyroidism. 

The men recruited from different sections of the country, in 
the late war, showed that there was a great deal of goiter in 
certain districts, but although probably these goiter districts are 
such because of the drinking water, it still has not been shown 
what factor in these waters causes the development of goiter. 
Drinking water low in mineral content has seemed to promote 
the development of goiter. Large amounts of minerals may kill 
the cause of goiter. However, it has long been known that an 
individual going to a goiterous district might avoid goiter by 
drinking imported water, or by drinking the water of the region 
only after it was boiled. McCarrison seemed to show that fecal 
contaminated water caused goiter, and that goiter was pre- 
vented by furnishing pure water for drinking purposes. He 
showed in his original investigations that about 5 per cent, of 
children born of goiterous parents were cretins, and that 63 per 
cent, of the children of parents with goiter were born with con- 
genital goiter. 

Pregnancy should, if possible, be prevented in Graves' disease, 
and if pregnancy occurs, and serious symptoms develop, the 
pregnancy should be terminated. A goiter may become so con- 
gested during parturition as to cause dyspnea ; any cystic adeno- 
ma of the thyroid may rapidly enlarge from some acute infec- 
tion and cause sufficient dyspnea to require removal of the fluid. 

Intrathoracic goiters are probably more frequent than has 
been noted, and when they occur, cause more or less constant 
dyspnea by pressure on the trachea. The associated enlarge- 
ment of the thymus gland which occurs in perhaps 50 per cent, 
of exophthalmic goiter cases is probably not a cause of Graves' 
disease, and it may not add, unless from pressure, any unpleas- 
ant symptoms to the case. It is possible that it hypertrophies 

27 



41 S THE PRINCIPLES OP THERAPEUTICS 

to help do what the thyroid is not well doing, or to control what 
the thyroid is over-doing. The thymus is more likely to be 
enlarged in exophthalmic goiter in young people than in older 
individuals. Also, when the thyroid in these cases grows 
smaller and lessens its activity the thymus gland is likely to 
diminish in size. 

A goiter that is largely cystic or largely colloid is probably 
not hypersecreting, and is ordinarily not toxic, while a hyperplas- 
tic goiter is either toxic, or can easily be irritated to produce a 
toxemia and Graves' disease. 

The term thyrotoxicosis is applied to the toxic symp- 
toms produced by an over-acting thyroid. The definite term 
of hyperthyroidism when there are the symptoms of Graves' 
disease, and hypothyroidism when there are symptoms of 
marked undersecretion seem to be useful and- good terms, but 
for the large number of border-line cases, in which there are only 
a few symptoms of hyperthyroidism or a few symptoms of hypo- 
thyroidism, the term dysthyroidism is perhaps better, which 
signifies a disturbance of the function of the thyroid gland. It 
is also quite probable that some function of the thyroid may be 
increased and other functions decreased. Therefore, neither 
term of hyper- nor hypo-thyroidism would be applicable. 

To determine that a thyroid is enlarged when such enlarge- 
ment is not in evidence, the head should be bent backward and 
turned from side to side while the gland is manipulated. If by 
auscultation of the thyroid arteries loud circulatory sounds are 
heard, the thyroid is receiving too much blood and is probably 
hypersecreting. 

It is not recognized that in every serious illness the thyroid 
is an important part of the body in fighting infection, and re- 
peated infections may wear out the thyroid gland. In some 
serious conditions the thyroid may need assistance during the 
infection, either by small doses of an iodide, or even by very small 
doses of thyroid gland substance, or possibly by minute doses 
of thyroxin. The thyroid gland is always disturbed in tuber- 
culosis, and some of the symptoms are due to such a disturb- 
ance. Goiter is frequently in childhood, and sometimes in 
adults, due to diseased tonsils. 



THYROID GLAND 419 

There may be thyroid disturbance when there is recurrent 
severe headaches, in epilepsy, in psychoses, in dementia pre- 
cox, and perhaps in other insanities. Some statistics have 
shown that in 25 per cent, of insane women there is goiter. 
These statistics do not state in how many of these cases there 
were focal infections in the mouth, which represent the most 
frequent causes of dysfunction of the thyroid. In subsecretion 
of the thyroid there may be mental depression and melancholia. 
Enlarged goiters of the right side may, by pressure, cause 
paralysis of the recurrent laryngeal nerve, therefore, before any 
operation on the thyroid is done, a laryngoscopic examination 
by an expert should be made. 

In toxic goiter with a rapid heart there may be no myocardial 
changes, but if the tachycardia continues, the heart may hyper- 
trophy and later, if the disease progresses, myocardial degenera- 
tion will occur. 

The thyroid is always disturbed in syphilis, and is injured by 
mercury and arsenic, and when idiots have insufficient thyroid 
glands congenital syphilis should be suspected. 

The emaciation so frequently seen in toxic goiter or 
Graves' disease may be due to two causes, one being the 
increased activity of the metabolism from the increased 
amount of thyroxin, i.e., the energy is enormously increased; 
the other cause may be the inability of the thyroid to prop- 
erly care for iodine, and an extra amount of iodine in the body 
will cause loss of weight. In uremic poisoning there is prob- 
ably some disturbance of the thyroid and of the parathyroid 
glands. 

Real inflammation of the thyroid, thyroiditis, is not frequent, 
but may occur from infection in the mouth, throat or larynx, 
and especially from the tonsils; but abscess of the thyroid gland 
is very rare. 

Reflex causes of goiter from disturbances of the pelvic organs 
in women is less and less frequently referred to in literature. 
There is no doubt that in some instances with uterine and 
ovarian disturbances the thyroid, which is so closely associated 
with the function of these organs, becomes disturbed, hyper- 
trophies, and hypersecretes. It is the writer's belief, however, 



420 THE PRINCIPLES OF THERAPEUTICS 

that hyperthyroidism in the majority of cases is caused by 
infection in the mouth or adjacent sinuses. 

Hypersecretion. — To primarily prevent goiter and disturb- 
ances of the thyroid gland all focal infection in the mouth and 
adjacent sinuses must be eradicated. Also goiter may be pre- 
vented by small doses of an iodide, given intermittently, or by a 
small amount of iodine vaporizing in the sleeping rooms, or in the 
school-rooms of girls and boys who are about reaching puberty, 
at which time girls especially are likely to have enlargement of 
this gland. 

If it is impossible to determine by the symptoms that the 
thyroid is hypersecreting, small doses of an iodide, and best so- 
dium iodide, as 0.05 to 0.10 Gm. (about 1 or 2 grains) once or twice 
a day, will aggravate the symptoms, provided that the gland is 
hypersecreting or about to furnish an abnormal amount of secre- 
tion. Border-line disturbances caused by the thyroid may be 
improved by such iodide treatment. 

The symptoms of hyperthyroidism, which has been termed 
Graves' disease and Basedow's disease, and which Plummer well 
terms " thyrotoxicosis, " or poisoning by thyroid, are as follows: 
nervous irritability; insomnia; hot flashes; increased perspira- 
tion which may be due to suprarenal action on the sympathetic 
system (the suprarenals are always disturbed, often enlarged, 
in hypersecretion of the thyroid); tachycardia; tremors; loss of 
weight ; exophthalmos ; digestive disturbances which may be due 
to the disturbance that caused the thyroid trouble, i.e., various 
mouth infections; and, later, cardiac weakness. There may be 
hyperchlorhydria. Often these patients are too hot, and suffer 
from the heat in hot weather. There may be hypertension, 
which is probably due to coincident suprarenal or pituitary 
disturbance, although it is disputed that the suprarenal gland 
takes much part in the physiology of the blood-pressure. 
These patients also may be subject to psychoses. They often 
have irregular night sweats, diarrheal attacks, and attacks of 
polyuria. Many of these symptoms may precede the actual 
hypersecretion symptoms. Enlarged thymus occurs in nearly 
half of the cases of Graves' disease, but it is doubtful if it in- 
1 creases the disturbance of the patient, and its secretion may 



THYROID GLAND 42 1 

inhibit the extra metabolism caused by the increase in thyroid 
activity. If the thymus is much enlarged, its pressure on the 
trachea might be a cause of the sudden death which sometimes 
occurs in thyroid operations. 

Hypersecretion of the thyroid, if not toxic, causes increased 
cerebral activity, sleeplessness, and a neurotic condition. A 
thyroid that is furnishing an over-amount of normal secretion 
causes the interesting personalities and the vivaciousness as 
seen in many of our American women. And the reverse is true; 
a diminished secretion causes mental depression, mental apathy 
and lack of vivaciousness, if not moroseness. 

Graves' disease is very much more serious when it is fully 
developed in men than in women, although, fortunately, real 
Graves' disease is very much less frequent in men than in women, 
perhaps occurring in men in not more than 20 to 30 per cent, of 
the cases. If it is associated with much adrenal disturbance, 
especially if there is enough adrenal disturbance to cause darken- 
ing of the skin and a low blood-pressure, the prognosis is bad. 

A thyroid patient is always too hot or too cold. There 
seems to be a vasomotor ataxia; their peripheral circulation 
seems not to be in normal relation with the outside temperature. 
Hyperthyroidism may increase the temperature, even one or two 
degrees, especially in the afternoon, and sometimes with a heart 
that is rapid there is a rise of temperature on the least exertion. 

Besides the pituitary, suprarenal, and thymus glands, the 
parathyroids, the pancreas, and the ovaries may be disturbed in 
hyperthyroidism. Some of these glands may have their secre- 
tion lessened, and some may have their secretion increased. 
Therefore, the composite symptoms which comprise the phe- 
nomena of Graves ' disease are caused by disturbance of many 
glands. 

Glycosuria not infrequently occurs in hyperthyroidism. 
Sometimes there is a diminution of the polymorph leucocytes. 
Very generally in hyperthyroidism there is an increased nitro- 
gen output due to the extra activity of the tissues caused by too 
much thyroxin. Also the increased rapidity of the heart, the 
rapid circulation, and the mental irritability all tend to in- 
crease metabolism, cause waste and consequent loss of weight. 



422 THE PRINCIPLES OF THERAPEUTICS 

Some of the increased irritability is caused by the increased 
loss of calcium from which these patients sometimes suffer, due 
perhaps to a disturbance of the parathyroids. 

Various tests have been suggested to conclude whether or not 
the thyroid is in trouble, in border-line cases. Pressure on the 
eye-ball to cause slowing of the pulse is of no great diagnostic 
value in Graves' disease. Goetsch 's test is made by injecting 
y 2 a c.c. of a i to iooo solution of epinephrine into the deltoid 
muscle, which tends to cause a rise in pulse-rate and in blood- 
pressure and an aggravation of the symptoms in hyperthyroid- 
ism. Goetsch 1 states that he has carried out his test in 300 
cases of thyroid disease and in 100 conditions simulating hyper- 
thyroidism. His technique is to place the patient at rest in bed 
for at least a day before the injection as necessary to reduce 
nervous irritability and excitation and cause the epinephrine 
hypersensibility to be more evident. Before the injection two 
or three readings at five minute intervals are taken of the 
systolic and diastolic blood-pressure, of the pulse-rate, and of 
the respiration. If these three readings are fairly constant, the 
epinephrine in the above dose is injected into the deltoid. 
Then the pulse, blood-pressure and respiration readings are 
made every two and a half minutes for ten minutes, then every 
five minutes for one hour and then every ten minutes for half an 
hour longer. At the end of one and a half hours, or less, the 
reaction has usually entirely passed off. Some reactions 
are noted in less than five minutes after the injection 
of the epinephrine solution, and a positive reaction is 
evidenced by an early rise in the systolic and a fall in the 
diastolic blood-pressure. If the reaction is very, mild only the 
fall in diastolic pressure may occur, "in the course of thirty 
or thirty-five minutes there is a moderate fall of pulse and 
blood-pressure, then a characteristic secondary slight rise, then 
a second fall to the normal in about one and a half hours. " 
During this time all of the nervous symptoms complained of by 
the patient are increased in intensity. A normal person seems 
to show no, or at least very slight, reaction to this injection. 
Also Goetsch says that "in colloid goiter cases without symp- 

1 Penn. Med. Journ., May, 1920, p. 431. 



THYROID GLAND 423 

toms of hyperthyroidism the reaction is negative." Conditions 
presenting some of the symptoms of thyroid disturbance but 
without hyperthyroidism react negatively to this injection, and 
Goetsch states that the greater the amount of hyperthyroidism 
present the more positive and decided is the reaction. 

A most useful simple test is that with an iodide. Almost 
invariably a few doses of an iodide will increase the symptoms, 
if the case is one of Graves' disease, and such treatment is 
perfectly safe, even if the administration of a small dose of thy- 
roid is questionable. Another test is to determine the sugar 
tolerance, an intolerance being supposed to show hyperthyroid- 
ism, perhaps due to coincident disturbance of the pancreas and 
of the posterior pituitary. This very fact that so many other 
glands are involved in the sugar metabolism seems to minimize 
the value of this test. 

The cause of hypersecretion of the thyroid is probably, 
occasionally, some nervous disturbance, as has been noted in 
sudden exophthalmic goiter from sorrow and from mental shock. 
It is, possibly, quite frequently due to disturbaDces of the uterus 
or ovaries in women, but the most frequent cause is some chronic 
toxemia or infection, especially when that is located in the 
mouth and throat. Diseased tonsils are frequently the cause of 
thyroid disturbances, and many times removal of infected ton- 
sils cures the goiter and the hyperthyroidism. The same suc- 
cess generally follows the removal of infected teeth. 

Occasionally the thyroid disturbance is due to its attempt 
to compensate for some disturbance or mal-function in some 
other part of the body. Such instances are the ones in which 
thyroid feeding has been said to cure an exophthalmic goiter 
case. These cases are rare. Such a thyroid disturbance, 
namely, hypertrophy and increased secretion, may be because 
the gland is attempting to detoxicate toxins in the blood, 
perhaps even when such toxins proceed from intestinal dis- 
turbance. Certainly an added amount of toxins absorbed 
from the intestines will aggravate any case of Graves' disease, 
hyperthyroidism, or thyrotoxicosis. Therefore some cases of 
simple thyroid disturbance have been corrected by correcting 
intestinal toxemia, and in every case of hypersecretion foods 



424 THE PRINCIPLES OF THERAPEUTICS 

that cause gastrointestinal disturbance should be interdicted, 
the bowels should move daily, and fermentation should be 
corrected. All purin foods more or less stimulate the thyroid, 
and, consequently, they should be removed from the diet; 
hyperthyroid patients should not receive tea, coffee, or meat. 
Patients who have a tendency to hypersecretion should abstain 
from all foods and drugs that increase the thyroid activity. 
Alcohol must always be prohibited in thyroid cases. 

Any constantly recurring excitement, especially mental 
irritation, may cause hyperthyroidism in an individual who has 
that tendency. As just stated, pelvic disturbances, and 
especially ovarian mal-function and uterine growths may cause 
hyperthyroidism. Graves' disease may or may not be aggra- 
vated by pregnancy, but if the extra thyroid secretion is needed 
and utilized during the pregnancy, the hyperthyroidism symp- 
toms are likely to again develop soon after parturition. Ab- 
normal and excessive sexual excitements will cause hyper- 
thyroidism. 

There is often hyperthyroidism in tuberculosis. Fatal 
heart disturbances in hyperthyroidism probably are frequently 
due to coincident infection from the mouth, namely, to the 
streptococcus viridans, although any heart disturbance will be 
excessively aggravated by the tachycardia of Graves' disease, 
and the heart muscle must wear out and eventually dilatation 
will occur. 

More or less disturbance of the sympathetic system occurs 
in Graves' disease, and sympathetic ganglia have been found 
degenerated. Dilatation of the blood-vessels back of the 
eye seem to be the cause of the exophthalmos which occurs 
so many times in Graves' disease, and when the circulation is 
quieted and the patient improves, the exophthalmos improves. 
It is either improved or cured after the removal of a goiter, 
and it is not in evidence after death. Therefore, whatever 
is the actual cause of exophthalmos, it is closely associated 
with hyperplasia and hypersecretion of the thyroid gland. 

There are many causes of hyperthyroidism, but whatever 
other symptoms are present, associated with Graves' disease, 
producing various kinds of clinical pictures, part of that clinical 



THYROID GLAND 425 

picture is always caused by hypersecretion of the thyroid. 
In other words, the thyroid disturbance is the most important 
part of the pathology of Graves' disease, as the disturbance of 
the pituitary is the most important part of acromegaly. 

Whatever it is that has disturbed the thyroid, the majority 
of symptoms in Graves' disease seem, from Kendall's and from 
Plummer's investigations, to be due to an increased amount of 
thyroxin produced by the gland. This thyroxin, reaching all 
the cells of the body, and, in an excessive amount, enormously 
increasing their activity and increasing all metabolism, seems 
to be the real cause of many of the symptoms of this disease. 
Also, many of the symptoms of Graves' disease could occur even 
with an intermittent hypersecretion of the thyroid gland, as the 
thyroxin circulates in the tissues, according to these investiga- 
tors, for two weeks or more. Consequently, a one day's extra 
dose of thyroxin could cause symptoms for many days to 
come, even if the thyroid quieted down and did not furnish 
the extra secretion daily. Basal metabolism is increased in 
hyperthyroidism, and anything that increases the temperature 
increases metabolic activity, and hence increases the basal 
metabolism. The increased nervous irritability and muscle 
restlessness as well as the rapid heart will increase the basal 
metabolism in these thyroid patients. Therefore any drug 
that will increase the basal metabolism, such as strychnine, 
caffeine, and atropine in small doses, should not be given 
patients who have hyperthyroidism. 

Basal metabolism is determined by calorimetric measure- 
ments of respiratory exchange, namely the oxygen intake and 
the carbon dioxide output. Needless to state that such deter- 
mination can only be made in a hospital or laboratory with an 
equipment for such scientific investigation, and this phrase, 
namely, "basal metabolism" is based upon what has been found 
normal for an individual at rest from twelve to eighteen hours 
after a meal. As it has been shown by Kendall and Plummer 
that the secretion of thyroxin from the thyroid determines the 
speed of the rate of basal metabolism, and that this rate is 
greatly increased in hyperthyroidism and greatly decreased in 
hypothyroidism, a determination of basal metabolism in a thy- 



426 THE PRINCIPLES OF THERAPEUTICS 

roid patient is of diagnostic and prognostic interest. Also 
while the patient is under treatment repeated determinations of 
the basal metabolism will disclose the success of the treatment. 
If a determination of the basal metabolism showed that it was 
not increased, hyperthyroidism and thyrotoxicosis could be ex- 
cluded. If there was great increase in basal metabolism, hyper- 
thyroidism is in evidence. Increased suprarenal activity may, 
however, also increase basal metabolism. If the determination 
showed that the basal metabolism was greatly reduced, hypose- 
cretion of the thyroid could be diagnosed. 

Kendall thinks that besides thyroxin the amino acids, protein, 
creatin and creatinin are also stimulants to basal metabolism. 

Treatment of Graves' Disease: — As prevention is better than 
cure, it is necessary to carefully study all benign goiters, 
especially in women, who so regularly during the child-bearing 
period have this gland normally disturbed. Therefore, as the 
thyroid normally hypersecretes during menstruation and during 
pregnancy, if there is a goiter, it may be stimulated to produce 
toxic symptoms, i.e., it may finally develop into Graves' disease. 
Hence all causes of enlargement of the thyroid gland should be 
sought and removed, if possible. Also, iodine or iodide treat- 
ment should be instituted, to ascertain if the colloid can be 
diminished and the gland reduced in size. 

If all sources of infection have been removed, or none found, 
and if an iodide does not cause a benign goiter to become nearly 
normal in size,- its surgical eradication should be considered. 
This does not mean that every goiter should be removed, but 
the probability of a patient having trouble from a goiter should 
be very seriously considered. 

At the present time there is a strong feeling that in Graves' 
disease, in hyperthyroidism, and in thyrotoxicosis operations on 
the thyroid gland have been too frequent, and that the medical 
treatment is the safest, and generally offers the best future 
prognosis. Briefly, the treatment should be absolute rest, 
mental and physical. The diet should be milk and cereals, per- 
haps a few green vegetables, later eggs and vegetable proteins. 
Meat in all forms, and tea and coffee should be prohibited. The 
patient should receive an extra amount of calcium, besides 



THYROID GLAND 427 

what he gets in his milk. Bromides may be, at first, necessary, 
but soon are not required. The hydrobromide of quinine in 
large doses has often been successful in quieting the tachycardia. 
Sometimes the tincture of strophanthus acts well. Thymus 
gland extracts many times seem valuable in favorably modifying 
hyperthyroid symptoms. The bowels should move daily, and 
intestinal fermentation should not be allowed. The diet should 
be so arranged that gastrointestinal indigestion does not occur. 
But of all treatments the most important is absolute rest. If 
in spite of this rest the patient does not do well, the heart con- 
tinues rapid, and the thyroid is still over-active, other treat- 
ments must be considered. 

Injections of hot water into the thyroid gland, while at 
times successful, is not good treatment. Injection of quinine 
and urea hydrobromide is dangerous treatment. Pressure on 
the neck and ice applications are not good treatment. There is 
a difference of opinion as to the value of ligating the thyroid 
arteries, one or two at a time, on account of the great 
circulation through the thyroid, although some of the most 
able surgeons believe such ligations to be of advantage and 
life-saving. 

Radical operations during an exacerbation of the symp- 
toms seems generally inexcusable. The danger is very great 
from this extra amount of secretion from the thyroid on 
account of its action on the heart. If the heart does not 
quiet, and the symptoms do not abate with rest, the prog- 
nosis from thyroidectomy is not good. Also, the more there 
are lymphoid enlargements, as enlarged tonsils and adenoids, 
and the more there are lymphatic gland enlargements, the 
greater the danger from any operation. An enlarged thy- 
mus has seemed to increase the danger from the operation, 
but some surgeons do not think that it ever contraindicates 
an operation. 

Before operative measures should be considered, it is well 
to try the x-ray treatment of the thyroid. The x-ray has been 
especially recommended for the treatment of large thymus 
glands, and we know the thymus can be frequently made 
smaller by radiations; but it is still a question whether 



428 THE PRINCIPLES OF THERAPEUTICS 

the thymus gland is adding to the undesired symptoms in 
Graves' disease, or is trying to combat these symptoms. 

Before using the x-ray treatment on the thyroid gland, it 
should be noted that occasionally the symptoms are made 
worse by it. Improvement by such treatment is shown by 
slowing of the heart, increase in weight, diminution of the 
cerebral irritation, and better sleep. There is no rule as to how 
long the treatment should be continued. Sometimes, how- 
ever, the thyroid gland has rapidly changed its activity to a 
condition of hypothyroidism, and sometimes the x-ray treat- 
ment has seemed to have been the cause of death. 

Radium treatment of the thyroid is now advised, and many 
cases of improvement have been noted, but it is doubtful if the 
success is commensurate with that caused by treatment with 
the x-ray. 

Serums prepared from thyroidectomized animals have been 
used in hyperthyroidism, but these serums probably represent 
the solutions of suprarenal, pituitary, and other glandular 
extracts without the thyroid. Hence they cannot really cause 
antagonism to hyperthyroidism and may do harm by adding to 
the blood extra amounts of secretions from these other glands, 
which glands may be hypersecreting in the patient to whom 
the treatment is administered. 

However much statistics may show that the majority of 
hyperthyroid patients should not be operated upon, still every 
surgeon and internist has had patients who, after improve- 
ment from medical treatment, could not remain well until 
after thyroidectomy. Apparently, all patients with severe 
symptoms of thyrotoxicosis should receive medical treatment 
only (unless in some cases ligations are advisable), and while 
the majority of thyrotoxicosis patients may be more or less 
permanently improved or cured by such treatment, even if 
they have recurrences, some patients remain chronic invalids 
until they are operated upon. As above stated, the general 
trend to-day is to do fewer and fewer operations on patients who 
suffer from hyperthyroidism; but perhaps more patients should 
be operated upon who have for the time being benign goiters 
that may later cause hyperthyroid symptoms. 



THYROID GLAND 429 

The better the heart, of course the better the prognosis of 
operation. If there is myocardial degeneration as determined 
by symptoms and tests, the risk of operation is great. The 
length of time the patient has had more or less hyperthyroid 
symptoms does not seem to be of great importance in determin- 
ing the operative risk, but the condition of the heart is of 
primary importance. 

Pressure symptoms may call for immediate operation, and 
a malignant growth of the thyroid gland should generally be 
surgically removed, unless x-ray treatment is deemed better. 

The surgical mortality is greater than has been stated, 
some patients dying perhaps from a thymus gland pressure, or 
from an intrathoracic thyroid, others from shock, perhaps 
from the great amount of thyroxin thrown into the circulation 
by the nervous excitation before the operation or by careless 
manipulation of the gland, some because of degeneration of the 
heart muscle, and some because of a lymphadenoid condition, 
the so-called lymphatic state. Webster has found that one 
cause of sudden death after thyroid operations is collapse of the 
trachea, due to a softening of the cartilage by the long pressure 
of the enlarged gland. The unsatisfactory after effects are 
that too many of the parathyroids have sometimes been 
removed, although this is now rare. Sometimes there is injury 
to the recurrent laryngeal nerve, with paralysis of the vocal 
cords. Sometimes, if too much of the gland has been left, it 
hypertrophies and hyperthyroid symptoms again occur; and 
sometimes so much of the gland has been removed that hypo- 
thyroidism occurs. In other words, the surgical treatment of 
exophthalmic goiter to-day should not be considered until 
prolonged medical treatment has been shown to absolutely fail. 
If necessary, months should be given to the cure of an exoph- 
thalmic goiter patient, and even after surgical removal of half 
or two-thirds of the gland, prolonged medical treatment must 
be instituted before the patient is cured. 

To sum up the treatment of Graves' disease, it may be stated 
that it is properly a medical disease, and should be medically 
treated; that if, after prolonged rest and proper management, 
the heart does not quiet and weight is not gained, and several 



430 THE PRINCIPLES OF THERAPEUTICS 

examinations of the basal metabolism do not show improve- 
ment and the patient is still racing at high speed, the roentgen- 
ray treatment, or radium treatment, of the thyroid should be 
tried for a considerable length of time. If there is no permanent 
cure from these treatments, at least there will be enough 
improvement to consider the advisability of surgery. On the 
other hand, thyroidectomy seems inexcusable during active 
thyrotoxicosis, when there are signs of cardiac degeneration, 
when there are signs of much suprarenal associated disease, 
and when the patient is typically lymphatic. 

Hyposecretion. — The symptoms of cretinism and of myxedema 
are well known, but many symptoms caused by hyposecretion 
of the thyroid are not recognized. Absence of the thyroid, or 
of its secretion, in infancy causes cretinism. With diminished 
thyroid secretion in young children, there is slow growth, and a 
general lack of mental and physical development. Other symp- 
toms from hypothyroidism which may occur at any age are a 
dry skin, sometimes almost an ichthyosis, and many times eczema, 
especially around the mouth, nose, and ears, and sometimes 
chronic eczema in adults. The thyroid secretion is decreased in 
amenorrhea, in chlorosis, and in the depressant forms of hysteria, 
and hyposecretion is often one of the causes of the vomiting of 
pregnancy. Epilepsy developing at the time of the menopause 
may be associated with subthyroid secretion, and melancholia 
is frequently associated with hypothyroidism. Adiposis dolorosa 
and obesity are associated with hyposecretion of the thyroid. 

The thyroid normally begins to lessen its secretion after 
forty-five. At the time of the menopause in women, if its 
secretion has not diminished, hot flashes, rapid hearts, and 
general circulatory disturbances are in evidence. If its secre- 
tion diminishes too rapidly the woman puts on weight. Also 
men who, from forty to fifty, rapidly add weight often have 
hyposecretion of this gland, and senility is closely associated 
with its hyposecretion. Dry and shriveled skin, hard arteries, 
diminished general metabolism and sluggish mentality, i.e., 
senility, is hypothyroidism. 

Loss of hair, headaches, and frequently digestive disturbances 
may be due to hypothyroidism. Sometimes there is profuse 



THYROID GLAND 43 1 

hemorrhage, especially from the uterus, and bleedings from 
diffeient parts of the body, which may be due to, or at least are 
associated with, hypothyroidism, and may be cured by feeding 
thyroid. 

A normally acting thyroid is necessary for normal sexual 
functions of the female. When there is hyposecretion, these 
functions are interfered with and abnormal. There are several 
types of subthyroid secretion of the milder forms in women. 
One type has infrequent and scanty menstruation, though nor- 
mal periods, and vasomotor disturbances, as cold hands and feet, 
cold fingers and chilblains (the type seen in Raynaud's disease) . 
Other patients show subthyroid disturbances by a dry skin, 
falling of the hair, constipation, and a diminished activity of 
the whole system. Others have amenorrhea, add weight, have 
diminished sexual appetite, are more or less apathetic, and are 
often sleepy during the day. Other patients have a subnormal 
digestion, fatigue easily, have low blood-pressure, and are 
always weary; others have the symptoms of adiposis dolorosa; 
others show a subnormal condition of the thyroid by a disturbed 
surface circulation and sweating of the hands and feet; and still 
others have headaches. All of these conditions are improved 
by the administration of thyroid extract. 

If the secretion of the thyroid is much diminished, the whole 
basal metabolism is decreased; there is likely to be diminished 
secretions of the gastrointestinal tract; diminished oxidation; 
diminished excretion of salts; the nitrogen metabolism is dis- 
turbed; often there is obstinate constipation, with perhaps auto- 
intoxication from the bowels, with associated headaches; and 
occasionally epileptic fits occur, and sometimes dementia 
praecox. 

The nails become brittle in subthyroid patients, they lose 
their hair, and the teeth decay. There is very frequently a 
puffing of the hands, feet, face, or of different parts of the body, 
not a "real edema, but on the plan of myxedema, and there may 
be eruptions on the skin, all of which improve with thyroid 
feeding. 

Thyroid feeding in all of these cases will improve the condi- 



432 THE PRINCIPLES OF THERAPEUTICS 

tion and increase the basal metabolism which is diminished. 
The dose of thyroid needed is very small, perhaps not more than 
from Y± of a grain to, at most, 2 grains a day of the dried gland. 

All possible causes for the sub thyroid condition should be 
sought, and not infrequently the thyroid is decreased in activity 
by mouth infection, though not as frequently as it is increased 
in activity by such infection; but every thyroid gland that has 
been overworked at some time may underwork at a later time. 

Thyroideum Siccum. — Desiccated thyroid gland is prepared 
from the thyroid glands of animals, and must contain about 0.2 
per cent, of iodine. It occurs as a yellowish powder, and the 
average dose is 0.10 Gm. (ij^ grains). Thyroid preparations, 
unless carefully standardized, vary as to their iodine content. 
If there is any doubt as to whether the preparation is saturated 
with, or contains sufficient, iodine, coincident with the adminis- 
tration of the thyroid extract a small dose of iodine may be given, 
and best the sodium iodide, and 0.05 or 0.10 Gm. (about 1 to 
1 }-^ grains) a day is sufficient. Also, many times, one dose of 
thyroid extract a day is sufficient, or a small dose twice a day. 
The dose should vary within wide range, from perhaps 0.005 
Gm. to 0.30 Gm. or more a day. A small dose may be given 
two or three times a day, or a little larger dose once a day, or 
possibly a still larger dose once in three or four days, as thyroid 
extract has been shown to be stored in the system and used 
gradually as needed. The dosage, of course, must depend en- 
tirely upon the object for which the thyroid is given. 

Thyroxin. — Kendall's active principle of the thyroid gland 
for administration by the mouth can now be obtained, and it is 
stated to contain 65 per cent, of iodine. It is offered in tablet 
form of several sizes, the tablets containing 0.2 of a milligram, 
0.4 of a milligram, 0.8 of a milligram, and 2 milligrams respec- 
tively. 

The indication for this active principle is the same as for the 
dried thyroid extracts, except that it is much more potent, and it 
should be used at first in the smallest dose to determine its 
activity in the given individual. Over-dosage will soon develop 
the symptoms of hyperthroidism. When it is administered 
for hypothyroidism and the condition has been improved, a 



THYROID GLAND 433 

very small dose may be all that is necessary to continue the im- 
provement. The tablet of thyroxin should be taken on an 
empty stomach, crushed with the teeth and taken with plenty 
of water. At the same time the patient should take about 
1.30 Gm. (20 grains) of sodium bicarbonate, which seems to aid 
the absorption of the thyroxin. Just how many times a single 
dose a day should be given, or after a few doses just when it 
should be repeated, must be determined by clinical investiga- 
tion. The data so far offered largely relates to the injection 
treatment. 

Uses of Thyroid Preparations. — Ordinarily, thyroid prepara- 
tions are indicated only when there is some form of hypothy- 
roidism. However, in some depressed conditions in acute 
infection without delirium and without a rapid heart, small 
doses of thyroid may be of benefit, and perhaps when the de- 
toxicating power of the thyroid gland has been exerted to ex- 
haustion during an infection a little help may be of advantage 
to the patient. However, generally, such stimulation or aid to 
the thyroid may be given by a small dose of an iodide once or 
twice a day. 

When there are indications of defective growth in children 
very small doses of thyroid are generally indicated. This is 
true when the teeth do not well develop, the hair does not grow, 
the skin is dry, and there are enlarged tonsils and adenoids, 
subnormal temperature, and especially when there is sluggish 
mentality. The nearer the child approaches a cretin, the larger 
the dose of thyroid required, for a time at least. When the 
symptoms of hypothyroidism are but few and not very marked, 
the dose should be small, if it is given at all. 

It is difficult to determine that a child is a cretin until at 
least he is six months of age, and perhaps it cannot be deter- 
mined until he is a year old, and if the secretion is only deficient 
and not absent, such deficiency may not be determined until 
after the child is two or three years of age. A cretin is evi- 
denced by a thick tongue generally protruded between the lips, 
more or less drooling, sluggish dentition, imperfect hearing or at 
least imperfect recognition of sounds, the eyes are far apart, 
there is often conjunctivitis and eczematous patches about the 

28 



434 THE PRINCIPLES OF THERAPEUTICS 

face, there is likely to be enlarged tonsils and adenoids, and 
perhaps puffing of the eye-lids, especially in sporadic cases. 
These symptoms are associated with slow development of the 
teeth, slow growth, and later the mentality is that of a moron, 
or even that of idiocy. 

The dose for a cretin a year old may be considered as 0.06 
Gm. (1 grain) two or three times a day. If the thyroid is begun 
when the child is older, the dose is larger. Its favorable action 
is shown by an improved mentality increased general growth, 
and a better growth of the hair, nails and teeth. When im- 
provement is in evidence, the dose should be diminished, al- 
though a small dose should probably be given daily, or at least 
every other day, for months and perhaps years. In these cases 
the undesired action of thyroid is generally a tachycardia, and 
when this occurs the dose is too large and the administration 
should be stopped. After the heart has returned to normal 
rapidity, smaller doses should be given. 

Thyroid transplants have been tried in cretinism, but they 
must be termed a failure. They may help the child until the 
transplanted gland is absorbed, but the transplant does not con- 
tinue to grow. When the thyroid secretion is not entirely 
absent in a child, thyroid treatment for a time may stimulate 
the gland to increased activity, and the dose of thyroid extract 
may then be much diminished. 

With the minor symptoms of sub thyroid secretion in children 
the dose is very much smaller, even as little as 0.005 Gm. 
daily being often sufficient, and certainly 0.01 or 0.02 Gm. 
daily is generally enough. 

Certain types of eczema which occur in children are typical 
of sub thyroid secretion, such as occur at the orifices of the 
body, and as fissures under the ears, at the corners of the mouth 
or around the nostrils. These patients are often improved by 
thyroid. 

At any age dry, scaly skin, of all grades up to actual ichthyosis, 
with profuse desquamation, are benefited by thyroid, as all 
such cases have subthyroid secretion. 

Some children have a great deal of headache, cold hands and 
feet, and sometimes great lassitude, showing sluggish circu- 



THYROID GLAND 435 

lation. Many times these patients are improved by small 
doses of thyroid, all of these symptoms disappearing and the 
child becoming much improved, even when all other treatments 
have failed. The dose for such patients is not more than Ji 
grain, sometimes less, once a day for two or three weeks. In 
the beginning one larger dose may be given, as i grain. Many 
of these children show signs of insufficient calcium, and espe- 
cially if there is irritability of the nervous system, which 
suggests parathyroid disturbance, calcium is indicated. Some- 
times in imperfectly developing children a combination of a 
small dose of thyroid and a fair dose of thymus extract is 
indicated, or calcium in some form may be given without the 
thymus extract. 

Infantile obesity may be associated with subthyroid secre- 
tion, but is more likely to be associated with a disturbed 
pituitary secretion, probably a subsecretion of the posterior 
lobe of the pituitary. These children improve on small doses 
of thyroid and coincident doses of pituitary. But these cases 
are likely to be associated with disturbances of other endocrine 
glands, and a careful study of the patient may show what 
combination is needed and what the exact treatment should be. 
The abnormal growth associated with more or less obesity is 
generally due to pituitary disturbance. 

If puberty does not occur at the proper time, and especially 
in girls, there is generally a lack of thyroid secretion, and 
small doses of thyroid, with perhaps ovarian extract, or perhaps 
only small doses of iodine, is what these patients need, and such 
dosage should be given for a considerable period. Symptoms of 
nervousness, sleeplessness, and tachycardia, show that either 
the treatment is not needed at all, or the dose is too large. 
Chlorosis is often as well cured by the administration of 
thyroid extract as by the administration of iron, and when 
normal menstruation develops and continues the chlorosis 
disappears. 'Too profuse menstruation in young girls shows, 
generally, too much thyroid secretion, and mammary extract 
should be given as advised under the uses of the mammary 
gland. 

The importance of iodine saturation in young girls at or 



436 THE PRINCIPLES OF THERAPEUTICS 

before puberty has already been described, and such iodine or 
iodide treatment will prevent the development of simple 
goiter, to winch they are prone if they do not have sufficient 
iodine in their circulation. 

Sometimes thyroid extract in small doses combined with 
pituitary extract will cure nocturnal enuresis in children, 
especially if these children show symptoms of lack of develop- 
ment. 

Amenorrhea is of frequent occurrence in women who are not 
pregnant and is generally associated with more or less muscular 
. weakness, a tendency to sleep in the daytime, more or less indi- 
gestion, and with the deposit of fat on the breasts, over the 
shoulders, on the hips, and sometimes on the upper part of the 
arms. When this development is excessive, the type of disease 
termed adiposis dolorosa is in evidence, and that disease is 
undoubtedly due to a disturbance of the endocrine glands, and 
is always associated with subsecretion of the thyroid. This 
disease occurs in all degrees of intensity. At least in all of the 
moderate types, and generally in the more severe types, thyroid 
treatment is successful in aiding the patient, and sometimes in 
curing the condition. As soon as the woman menstruates 
normally and sufficiently, all the other symptoms are amelio- 
rated; she loses more or less weight although it may not come 
down to normal. On the other hand, having once shown this 
type of condition, unless her whole life is changed, either she 
marries, or she becomes pregnant, or something changes the 
whole condition of the endocrine glands, she is likely to have 
recurrences of this condition throughout her life. Sometimes 
such patients do not menstruate for months, to again begin for 
a period or two, and then stop again. Whatever the other 
treatment is, whether ovarian extract, ovarian residue, or 
corpus luteum, thyroid extract is always of great value. Some- 
times an iodide is all that the patient requires. The value 
of thyroxin for these patients has yet to be determined. 

When the menopause develops in women, weight is always 
added, and if the secretion of the thyroid is too greatly deficient 
at this time, weight is added rapidly, and more or less symptoms 
of hypothyroidism occur. Thyroid extract is the treatment for 



THYROID GLAND 437 

this condition. The dose required is generally not large, often 
best associated with an iodide. The pulse is always slow in 
these sub thyroid cases, the skin dry, and there is puffiness under 
the eyes, on the hands, or on the feet without any actual edema, 
i.e., there are symptoms of mild myxedema. 

If myxedema is really in evidence, the eye-lids are swollen, 
the teeth decay, the hair falls, hearing becomes impaired, men- 
tality sluggish, the blood-pressure low, the pulse-rate slow, and 
there are more or less digestive disturbances. Thyroid is the 
treatment, and it is curative. The dose of thyroid is always 
less when an iodide is added to it, and thyroxin may be found 
to be a most successful treatment. The dose of thyroid extract 
should be sufficient to cause improvement, and after improve- 
ment is in evidence the dose should be diminished, and then con- 
tinued at the amount required to keep the patient normal. 

Although there are many causes for obesity that' occurs before 
the age of forty-five or that occurs as an individual condition 
in a family that is not prone to stoutness, endocrine disturb- 
ance is generally at the bottom of trie condition. Thyroid 
feeding for this kind of obesity has often been carried to excess, 
and has often caused very undesirable symptoms; but associated 
with the proper diet and the proper amount of exercise, some 
thyroid treatment is generally advisable, perhaps associated 
with other glandular extracts. It should always be remembered 
that with patients who do not show other signs of subthyroid 
secretion, thyroid treatment may precipitate hyperthyroidism. 
On this account, many of the so-called obesity cures are danger- 
ous, and the sale of thyroid extract should be subject to the 
same restrictions as are the narcotics. 

Thyroid extract has been given in some of the toxemias, and 
particularly in the vomiting of pregnancy, and many times it is 
successful in this condition, although corpus luteum is now sug- 
gested for that disturbance ; but certainly normal thyroid secre- 
tion is necessary for the health of the mother during pregnancy, 
and if that gland is subsecreting, thyroid should be administered 
in small doses. Puerperal eclampsia, in which the urine gives 
no evidence of insufficiency of the kidneys, has been attributed 
to thyroid disturbance, and certainly in these cases thyroid ex- 



438 THE PRINCIPLES OF THERAPEUTICS 

tract iii very large doses has been successful in preventing and 
stopping convulsions. Also, large doses of thyroid will at times 
prevent the convulsions of uremia. But thyroid is only a small 
part of the treatment of the serious condition of either puerperal 
eclampsia or of uremia, and is only mentioned here to state that 
all these patients in this serious condition are improved by the 
administration of thyroid associated with other proper treat- 
ment. The dose in these conditions should be 10, 20 or even 
30 grains of the extract in the first six hours, and then repeated 
only as indicated, depending on the results and the symptoms of 
its action. 

At times epileptic attacks are associated with subthyroid 
secretion, especially the epilepsies which occur at the time of 
the menopause. Many of these cases may have their actual 
cause in mouth infection, which has irritated not only the brain, 
but the thyroid and parathyroid glands. It is possible that 
the parathyroids are always disturbed in an epileptic attack. 
Suffice it to say in this connection that cleaning the mouth 
and throat of infection, the administration of thyroid extract 
and of calcium salts will always ameliorate and sometimes cure 
this type of epilepsy. Also, the epilepsies that are aggravated 
at the time of puberty, or are aggravated during pregnancy 
should be managed on this same plan. More or less bromides 
should, of course, be given while the system is righting itself and 
the irritating substances, or the causes are being ehminated, but 
to perpetuate the detoxication of the system, unless there is 
contraindication against it, thyroid should be given with alka- 
line salts, and especially the calcium salts. All intestinal fer- 
mentation and putrefaction should be prevented in these cases, 
and generally the patients are better without animal proteins. 
The dose of thyroid in epilepsy cases need not be large, perhaps 
0.05 Gm. a day, and if this causes increased heart action the dose 
should be reduced. 

In some forms of digestive disturbances, especially in spastic 
constipation, small doses of thyroid are beneficial provided such 
a condition is associated with other signs of subthyroid secre- 
tion. Quite probably very small occasional doses of thyroxin 
will be found to be of great benefit in these conditions, but it 



THYROID GLAND 439 

should be emphasized that thyroxin is very potent, and as it 
is urged that thyroid extract should be given with the greatest 
of care, it should be more strenuously urged that thyroxin 
should be given with still greater care. 

In increasing blood-pressure as age advances, small doses of 
thyroid, given daily, or less frequently, especially if the skin is 
dry and there is tendency to chronic eczema, and the pulse is 
slow, are of very great benefit. Thyroid secretion is generally 
what the patient has begun to lack at this age. This evidence 
of lack of thyroid secretion may occur earlier in life, depending 
upon what the thyroid has had to do. If it is a woman and she 
has had many pregnancies, or if it is an individual who has had 
many serious illnesses, or has had some chronic disease that has 
caused more or less over-action and finally lessened action of the 
thyroid gland, thyroid extract is indicated and will be of benefit. 

Not infrequently the asthma which occurs in old age is pre- 
vented by thyroid, perhaps because it aids in properly combat- 
ing the irritations from mal-nitrogenous metabolism. At any 
rate, with high blood-pressure associated with asthma, thyroid 
is of benefit. Perhaps at times the reason that iodides have 
oeen very successful in certain forms of asthma is because they 
increase thyroid activity. 

While theoretically thyroid extract is contraindicated in pro- 
fuse hemorrhages , as it generally increases such hemorrhages, 
occasionally in hemophilia thyroid has been curative, but 
generally it has been a failure. However, in the peculiar 
hemorrhages seen at the time of the menopause in women, 
thyroid extract is sometimes a specific- The dose for this 
condition should be large, for a few days, and then it should be 
given in daily smaller doses. Sometimes this treatment is 
successful after all other treatments have failed, it causing 
cessation of hemorrhage, even when the bleeding has been 
from the bladder, rectum, mouth, nose, and many other parts 
of the body. 

Thyroid treatment is contraindicated when there are symp- 
toms of hypersecretion of the thyroid, when there are toxic 
symptoms from hyperthyroidism, when there is sleeplessness, 
delirium, or any cerebral excitation, when there is a rapid heart 



440 THE PRINCIPLES OP THERAPEUTICS 

or any irritability of the heart, generally when there are acute 
inflammations of the skin, and when there is progressive loss of 
weight. 

PARATHYROID GLANDS 

The parathyroids are small, kidney shaped, reddish bodies, 
four in number, two upper and two lower, which are more or less 
closely associated with the thyroid gland on its posterior aspect. 
There may be supernumerary parathyroids as there may be a 
supernumerary thyroid. 

Many of the symptoms after thyroid extirpation, long 
attributed to removal of that gland, are now known to have 
been due to the coincident extirpation of the parathyroids. 
Such symptoms are mostly of the convulsive type, and if more 
than two of the four parathyroids are removed, these symptoms 
develop and are quickly fatal. The symptoms from parathy- 
roid extirpation are tremors and muscle contractions, more or 
less tetanic in type. It has been shown that the tetany and 
cerebral irritations caused by such extirpation are probably 
due to a deficiency of the calcium in the blood, and the injection of 
parathyroid extracts or the administration of calcium will pre- 
vent or stop the muscular spasms. 

Macleod states that Noel Paton's investigations seem to 
show that the symptoms after parathyroidectomy are due to 
intoxication by guanidine, and therefore that one of the activi- 
ties of the parathyroid glands is to prevent the development of 
this muscle-irritating substance in the body in undue amount. 
Macleod then draws the conclusion that idiopathic tetany is 
probably due to an insufficiency of the parathyroid glands. 

After partial extirpation of the parathyroids in animals, not 
sufficient to cause tetany, there is loss of weight, dryness of the 
skin, eczema and loss of hair. 

The close association of the parathyroids with the thyroid 
would suggest their physiologic relationship to each other, and, 
though they have been found abnormal in thyroid disease they 
cannot assume the functions of the thyroid, however closely 
they may be associated with it in certain chemical relations. 
It would seem that the different forms of tetany and some of 



PARATHYROID GLANDS 44 1 

the peculiar muscle irritabilities seen in certain nervous diseases 
are due to disturbances of, or injuries to, the parathyroid glands, 
and in certain conditions they have been found suffering from 
hemorrhagic disturbances. 

MacCallum and his associates showed that the serious 
symptoms caused by parathyroidectomy were almost instantly 
cured by the intravenous injection of a solution of a calcium 
salt, five per cent, of either the acetate or lactate of calcium. 
When the solution was given by the mouth it was as effective, 
only it acted more slowly. The beneficial action lasted for 
twenty-four hours, when tetany would again occur, and again 
disappear on another injection or administration of the calcium. 
They found the potassium salts aggravated the symptoms of 
the tetany. There would seem to be no question that the 
parathyroids have, as one function at least, control of calcium 
metabolism or of calcium absorption and assimilation. When 
there has been great calcium loss, and nervous irritability is 
the consequence, as sometimes occurs with too frequent preg- 
nancies, and with the cerebral excitement (spasmophilia) that 
occurs in serious illness, and that often occurs in hyperthyroid- 
ism the administration of calcium is sedative to the whole 
nervous system. Probably in these conditions the parathy- 
roids have either been overworked and have become insuffi- 
cient, or they are not functioning properly. 

Kendall 1 suggests that an important function of the para- 
thyroids is to convert ammonium carbonate of the protein 
metabolism of the body into urea, and urea may be formed in 
various parts of the body. 

Halsted 2 showed that parathyroid tissue could be success- 
fully transplanted into the thyroid gland and into the rectus 
muscle of the abdomen in 61 per cent, of the cases, provided 
there was deficiency of parathyroid in the animal, in other 
words, that more than one-half of the parathyroid tissue had 
been removed. If there was no deficiency the parathyroid 
transplant was not a success. Therefore it would seem wise 
when, in the human subject, the parathyroid glands must be, 

1 Journal A. M. A., March n, 1916, p. 811. 

2 Journal of Experimental Medicine, No. 1, 1909. 



44 ^ THE PRINCIPLES OF THERAPEUTICS 

or have been inadvertently, removed, that parathyroid tissue 
should be transplanted, especially as Halsted showed the 
tissue could survive and prevent tetany for months. One para- 
thyroid gland embedded in the rectus muscle seems to be 
sufficient. Unfortunately more recent attempts at trans- 
plantation of these glands have caused only temporary success. 

Underhill has shown that these glands are concerned in carbo- 
hydrate metabolism; also they have seemed to have something 
to do with the calcification of bone in growing animals. 

Infantile tetany would seem to be due to parathyroid dis- 
turbance, the symptoms being somewhat similar to parathyroid 
extirpation, and Noel Paton and his associates, of Glasgow 
University, conclude that idiopathic tetany and the tetany 
following extirpation of the parathyroid glands are similar, the 
symptoms being due to such chemical mistakes as cause poison- 
ing from guanidine or its derivatives. 

Howland and Marriott, of Johns Hopkins, have found a 
diminution of calcium in the blood serum in cases of tetany. 
This bears out the clinical fact that the administration of 
calcium inhibits or prevents tetany, although, if symptoms of 
tetany are present, it is advisable to give sedatives, and prob- 
ably bromides are the best, until the blood has become again 
saturated with calcium. 

As a quieter of the nervous system calcium and alkalies have 
long been known to be efficient, and the relation of hyper- 
acidity, or acidosis, to irritation of the central nervous system 
is of course well known. Consequently, the suggestion is not 
surprising that irritation of the parathyroids, which glands are 
so closely related to calcium metabolism, might be a cause or an 
associated cause of epileptic convulsions. The saturation of 
the body with alkalies, and especially with calcium, always more 
or less diminishes the frequency of epileptic attacks. The 
convulsions of eclampsia and of uremia are probably also 
associated with more or less acidosis and possibly more or less 
disturbance of calcium metabolism. Of course profound 
acidosis causes stupor and coma, but alkalies are always seda- 
tive to the nervous system, and more or less combat the serious 
nervous symptoms of acidosis. 



PARATHYROID GLANDS 443 

Quite the reverse of this condition was shown by Wilson 1 
and by McCann, 2 that extirpation of the parathyroids causes a 
condition of alkalosis due to a disturbance of the relations 
between the acids and bases. These experimenters agree that 
tetany is due to a condition of alkalosis. 

It is possible that while complete parathyroidectomy causes 
alkalosis of the system, dysfunction or hyperfunction of these 
glands might cause an acidosis, each condition corrected by 
chemical substances. If tetany is due to an alkalosis it seems 
rather paradoxical that calcium salts should cure it; however, 
perhaps no more paradoxical than that frequently hyperacidity 
of the stomach is cured by the administration of dilute hydro- 
chloric acid, which seems to prevent the developement of abnor- 
mal acids. Therefore the success of calcium salts in tetany may 
be due to the substitution of normally related alkaline salts for 
abnormal alkaline salts. 

Associated with the calcium function of the parathyroids is 
also the calcium function of the thyroid, ovaries, and testicles, 
and all of these glands play some part in the most interesting 
story of calcium. 

Winternitz has suggested that there is a disturbance of the 
calcium metabolism in tuberculosis, and it has been recognized 
that the more calcium given the tuberculous patient the better; 
i.e., plenty of milk and the administration of calcium salts. 
Tuberculous lesions are cured by local deposits of calcium salts. 

The amount of calcium used in the body is very small, and 
it has been estimated that only about o.oi per cent, of the cal- 
cium of the body is in the soft tissues ; it is practically all in the 
bones. There is more calcium relatively in the brains and 
bodies of children than in adults, consequently any diminution 
of the calcium makes them more likely to have tetany or convul- 
sions. Calcium* is retained by infants and children longer than 
by adults, and when an excess of calcium is administered, it is 
very slowly excreted. An increased excretion of calcium is 
generally associated with an increase excretion of magnesium, 

1 Journ. Biolog. Chem., 21, 1915, p. 169; and Journ. Biolog. Chem., No. 23, 
1915, p. 89. 

3 Journ. Biolog. Chem., No. 35, 1918, p. 553. 



444 THE PRINCIPLES OF THERAPEUTICS 

and they appear in the urine as phosphates. ButL. B. Mendel 
has shown that the administration of hydrochloric acid increases 
the excretion of calcium more than that of magnesium. 

The heart muscle, in certain weak conditions, is strengthened 
by the administration of calcium, and as above suggested, tuber- 
culous patients need an excess of calcium. Too frequent preg- 
nancies, or at times any pregnancy, may deplete the mother 
of her calcium, in order to properly nourish her fetus and for the 
fetus to properly grow. • If she is so depleted, fatty degenera- 
tions may occur, especially of the liver, also her bones may 
soften. 

The parathyroids have been found diseased and to have had 
hemorrhages into their tissues in some cases of tetany, but they 
have not been often found pathologic in gastric tetany. Al- 
though on account of the muscle irritability which is present 
in paralysis agitans the parathyroids have been thought to be 
in trouble in this nervous condition, this has not yet been proved, 
and they have been found normal in such cases. Parathyroid 
disturbance has been suggested as a cause of cataract, but there 
is no proof of this relationship. These glands have been found 
abnormal in the insane. 

Spasmophilia in acute infections may be due to a disturbance 
of the parathyroids. If there has been much loss of calcium 
from any cause, however, such calcium privation would account 
for the spasmophilic condition, and certainly in all serious infec- 
tions an extra amount of calcium should be given as soon as 
there is the least sign of cerebral irritation. " It is well to give 
extra amounts of calcium in the last months of pregnancy, es- 
pecially if the mother has loss of hair, -brittle nails, and decay 
of the teeth. 

It is possible that some of the paroxysms of whooping cough 
may be due to parathyroid irritation, and it has been suggested 
that hemorrhages into the parathyroids may be a cause of sud- 
den convulsions and death in infants. 

We may conclude that the parathyroids are closely associated 
with calcium metabolism; closely associated chemically with the 
substance guanidine that may cause muscle irritations; and, 
therefore, that these glands may be disturbed in all conditions 



PITUITARY GLAND 445 

that cause nervous irritation and convulsions. It is a fact that 
removal of the parathyroids will cause tetany, and that tetany 
is probably not alone due to a loss of calcium, but to some poison 
circulating in the blood or to an alkalosis, due to the removal of 
the parathyroid glands, and therefore to the absence of para- 
thyroid function.- 

Parathyroid extracts, given hypodermatically, are always of 
value after parathyroid extirpation, but ordinarily the adminis- 
tration of calcium is as efficient. 

We may sum up the uses of parathyroid extracts by stating 
that small doses of parathyroid may be of benefit in all cases of 
muscle irritability. The dose should be very small, and the fre- 
quency of its repetition or the length of time it should be given 
depends upon the condition for which it is used. Preparations 
of the glands may be obtained in the form of a powder or as 
tablets, the dose is about 0.006 Gm. (^fo g ram )> once or twice 
a day. However, it has not been shown that in such a condi- 
tion as paralysis agitans this extract is of any more value than 
is the administration of calcium, and in such serious conditions 
as eclampsia better treatment is large doses of thyroid combined 
with large doses of calcium and sodium salts. In other words, 
it has not been shown that parathyroid glandular extracts 
should be much used in medicine. 

PITUITARY GLAND 
Hypophysis Cerebri 

Description.— The pituitary body, or hypophysis, is located at 
the base of the brain in the sella turcica, and consists of two 
lobes; the anterior larger lobe is oblong in form, and the pos- 
terior smaller lobe is round. The pituitary body varies greatly 
in size, having an average weight, in the adult, of perhaps half a 
gram, and is relatively larger in the child than in the full-grown 
individual. There is a communication termed the infundibu- 
lum, more or less patulous, that connects the posterior lobe with 
the third ventricle. The anterior lobe is distinctly glandular in 
structure, resembling somewhat the thyroid, while the posterior 
lobe is composed- largely of nervous tissue and some glandular 



446 THE PRINCIPLES OF THERAPEUTICS 

cells. Sometimes the posterior lobe is termed the infundibular 
portion of the gland. The cleft (pars intermedia) between the 
two lobes of the pituitary body frequently contains a thick 
colloid material. Neither Cushing nor Goetsch have found the 
colloid of the pituitary body to contain demonstrable active 
principles. 

An active principle has been found in the anterior lobe which 
is termed tethelin, and this seems to represent the growth- 
producing element of this lobe. An active blood-pressure-rais- 
ing principle was long ago discovered in the posterior lobe and in 
the infundibular part of the gland, and extracts prepared from 
this portion of the gland stimulate smooth muscle fiber. 

Function. — While the pituitary body has long been recognized 
and named, its pathology was not noted until first described by 
Marie, in 1886, who first showed the relation of this gland to 
acromegaly. The activities of the gland in the last few years 
have been carefully studied and demonstrated by Harvey Cush- 
ing and his co-workers. ' It has been found that the activity of 
the anterior lobe of the hypophysis is entirely distinct from the 
activity of the posterior lobe and the infundibular portion, and 
that the infundibular structure and activities are similar to the 
posterior lobe structure and activities. It has been shown that 
the anterior lobe is essential to life; the whole of it cannot be 
removed without causing the animal's death. If a part is 
removed, though death is not caused, structural changes develop, 
such as abnormal deposits of fat, loss of hair, loss of sexual 
power, and atrophy of ovaries and testicles. There is also dis- 
turbance of the urinary secretion, sometimes polyuria, some- 
times glycosuria. There is often associated with such operative 
interference with the gland an hypertrophy of the thyroid, and 
in the various pathologic conditions of the pituitary the thyroid 
has been found hypertrophied, or at least its function is dis- 
turbed. Also if either gland is removed the other hypertro- 
phies, and after thyroidectomy it is the anterior lobe of the 
pituitary that enlarges. It has been shown that the posterior 
lobe and infundibular portion of the pituitary body may be 
removed without any very definite changes in the body and 
without causing death. 



PITUITARY GLAND 447 

Cushing and his co-workers Crowe and Homans, showed that 
separation of the hypophyseal stalk from the base of the brain, 
i.e. j separating the gland from the body, acted similarly to com- 
plete removal of the gland, and when the whole gland is 
extirpated the symptoms are lowered temperature, lowered 
blood-pressure, feeble pulse, slowed respirations, tremblings, 
twitchings, and finally death. 

Extracts prepared from the posterior lobe contain a blood- 
pressure-raising substance, and these extracts will cause con- 
tractions of the muscles, especially of smooth muscle fiber. It 
has, in the last few years, been demonstrated that this extract 
has a specific activity on the uterus, causing active contractions, 
especially when it is dilated. It has also been shown that this 
extract is an active stimulant to the muscular coat of the in- 
testine and promotes peristalsis. 

Cushing and, his co-workers have shown that the posterior 
lobe is actively concerned in sugar metabolism; if this lobe hy- 
persecretes glycosuria may be caused; if it under-secretes great 
tolerance to sugar develops, and if its secretion is absent the 
tolerance to sugar is excessive. The activity of this part of the 
pituitary body may be demonstrated by testing the indi- 
vidual's tolerance to large amounts of sugar. If 200 grams of 
sugar, which ordinarily causes glycosuria, does not cause that 
condition, a subsecretion of the posterior lobe of the pituitary 
may be considered as demonstrated, and sometimes the toler- 
ance to sugar is very great. 

It has also been found that extract from this posterior lobe is 
an active diuretic, perhaps only, however, because it raises the 
blood-pressure. This rise in pressure is not as rapid as that 
caused by suprarenal extracts, but it lasts longer. The pulse is 
slowed and the heart is strengthened by this extract. The 
slowing of the heart seems to be due to action on the vagus, and 
the strengthening of the heart to action on the heart muscle; 
the whole activity on the heart is not very dissimilar to that of 
digitalis. If much nervous tissue extract is included in the 
posterior lobe extract a secondary effect of vasodilatation is 
likely to occur. Operations in the region of the posterior lobe 
or any nervous disturbance in that region often causes polyuria 



448 THE PRINCIPLES OF THERAPEUTICS 

from the irritation, but a tumor growth of this lobe causes 
diabetes insipidus. 

Recently Houssay 1 and Leschke 2 seem to have shown that 
diabetes insipidus or polyuria is not due to deficiency of the 
posterior lobe or to decreased activity of the pars intermedia, 
but is due to disturbance, perhaps from pressure from these 
glands, of the tuber cinereum. However, it has been repeatedly 
clinically demonstrated that in diabetes insipidus hypodermatic 
injections of posterior lobe extract will almost immediately stop 
the polyuria and prevent the thirst, though this treatment must 
be frequently repeated and does not cure the condition. Conse- 
quently it seems demonstrated that hyposecretion of the 
posterior lobe of the hypophysis from any cause may produce 
such cerebral disturbance somewhere as to cause diabetes 
insipidus, and the administration of extracts of this gland 
temporarily cures the condition. 

After removal of the anterior lobe, injections of anterior 
lobe extracts will prolong life. After removal of a part of 
the anterior lobe of the pituitary the growth of animals and 
their sexual development is interfered with, but feeding anterior 
lobe or posterior lobe preparations, or both, to children who do 
not grow does not seem to increase their growth. 

Cushing has shown that the colloid secretion of the pars 
intermedia is discharged into the posterior lobe which is largely 
composed of nervous elements, and the combined secretions 
from these two parts of the pituitary pass on into the infun- 
dibular cavity and then into the third ventricle and from there 
into the cerebrospinal fluids. 

Macleod states that the posterior lobe furnishes an antacoid 
which stimulates the utilization of sugar in the body, and any 
irritation of the brain that could stimulate this part of 'the 
gland may cause a glycosuria, and injections of post-pituitary 
extracts cause a lowering of sugar tolerance. Also any irrita- 
tion of the posterior lobe may cause diabetes insipidus. 

Abel and Kubota have found histamin in the hypophysis 
cerebri which substance stimulates smooth muscle tissue even 

1 Endocrinology, 1918, No. 2, p. 94. 
2 Zeitschr. f. klin. med., 1919, No. 87, p. 201. 



PITUITARY GLAND 449 

in minute doses. This seems to be the substance of the poste- 
rior lobe that causes contractions of the muscles and acts on the 
uterus. This substance depresses the circulation and in large 
doses causes shock, and it may be this substance that causes 
the lowered blood-pressure when large doses of pituitary extract 
have been injected. While histamin is ingested more or less 
with our food, severe muscle injuries may cause a large amount 
of it to be absorbed, and the above investigators suggest that 
it may be one of the causes of traumatic shock. 

Weed and Cushing believe that extracts of the posterior lobe 
increase the circulatory activity of the choroid plexuses and 
hence increase the amount of cerebrospinal fluid. 

The pituitary gland is enlarged during pregnancy much as is 
the thyroid, and Cushing has found tha*t repeated pregnancies 
may so enlarge this gland as to cause transient bi-temporal 
hemianopsia which is caused by the pressure of the gland on the 
optic commissure. ' This gland also is more or less enlarged 
before or during menstruation, and such enlargement or the 
disturbed secretion is a frequent cause of so-called menstrual 
headaches, and, if the disturbed secretion or the enlargement 
persists, more or less permanent headache is caused. Such 
headache does not seem to be due to a hypersecretion, as 
the administration of whole pituitary gland preparation very 
generally stops or prevents the headache. 

An increased secretion or disturbed secretion from this gland 
may be a cause of dysmenorrhea and of profuse uterine hemor- 
rhage, and, as one of the functions of this gland seems to be to 
promote uterine contractions during parturition, it is quite 
possible that its increased secretion could cause sterility, 
miscarriage, or at least premature labor. 

The part of the gland that seems to be normally hyper- 

trophied throughout pregnancy is the anterior lobe, and if this 

lobe does not enlarge or increase its activity disturbances of 

metabolism may occur, such as puffing of the hands and feet 

and deposits of fat, and there may be disturbances of the 

calcium metabolism as shown by imperfect bone development 

of the fetus, and loss of teeth, brittle nails and loss of hair in 

the mother. Such pituitary disturbance is likely to be associ- 
29 



45° THE PRINCIPLES OF THERAPEUTICS 

ated with thyroid insufficiency and perhaps with parathyroid 
dysfunction. As far as the mother's pituitary secretion affects 
the child, however, it should be noted that McCord 1 found that 
both the pituitary and the suprarenal glands develop early in 
fetal calves, and he thinks that probably the fetus in utero is 
early under the influence of its own glands. 

Hypersecretion. — If the anterior lobe of the pituitary hyper- 
secretes in childhood and youth the individual grows abnor- 
mally large, and if the condition persists he becomes a giant. 
If he lives long enough, sooner or later the giant will become 
acromegalic in type on account of the secretion of the pituitary 
becoming abnormal; or the gland sooner or later, in tumor 
growths, hyposecretes. Hypersecretion of the anterior lobe 
after the individual is twenty years of age when the epiphyses 
of the bones are united will produce the acromegalic type of 
growth, namely, instead of the shafts of the bones growing 
excessively as in giantism (when the disease starts in childhood 
and youth) deposits occur at the ends of the bones, and some 
cartilage and tendons become bony. The irregular bone de- 
posits in the cartilages of the spine throw the alignment out of 
adjustment, and all kinds of spinal deformities occur, princi- 
pally kyphosis. The lower jaw is elongated by deposits of bone 
in the glenoid fossae, and prognathism occurs.^ There is an 
increased growth of hair on the body, warty growths may 
develop on any part of the body especially on the back, the skin 
becomes thickened and develops into folds, with deep furrows 
on the forehead, and the soft parts of the nose, face, and palms 
of the hands hypertrophy. As the disease progresses the thy- 
roid becomes disturbed, often subsecretes, and more or less 
myxedematous symptoms appear, with lowered blood-pressure 
and weakness of the heart; there is impotence in the male and 
amenorrhea in the female. 

More or less headache is always present, the intensity depend- 
ing upon the pressure from the enlarging pituitary body and 
possibly from its disturbed secretions. Possibly stimulation of 
the pars intermedia and the posterior lobe may cause increased 
cerebral pressure, due to an increased secretion from the choroid 

1 Journ. of Biolog. Chem., Baltimore, Dec, 191 5. 



PITUITARY GLAND 451 

plexuses and hence to an increased amount of cerebrospinal 
fluid. 

Very commonly pressure from the enlarged pituitary body or 
from tumor growth in this region on the optic commissure 
causes disturbances of the eye with narrowing of the visual fields. 

If the degeneration of, or the growth of the pituitary pro- 
gresses, various cerebral disturbances can occur, from epileptic 
convulsions to insanity; also cerebral symptoms from pressure 
may occur. 

Sooner or later, with the disturbance that probably started 
in the anterior lobe, the posterior lobe is disturbed, and if it 
hypersecretes glycosuria is likely to be a symptom, and if it 
hyposecretes there is increased tolerance to carbohydrates, more 
or less polyuria, and many digestive disturbances occur. 

Not every case of tumor growth in the sella turcica causes 
acromegalic symptoms, but in every case of acromegaly the 
pituitary gland is diseased. 

For a detailed description of the disease of acromegaly the 
reader is referred to the author's article in Buck's Handbook of 
the Medical Sciences, Vol. i. A description of the third case 
of acromegaly reported in America and the eighth in literature 
will be found in the author's article in the Transactions of the 
Association of American Physicians for 1897. An elaborate 
literature on the subject of pituitary diseases will be found in 
the book and articles published by Harvey Cushing. 

The treatment of this disease which generally has a duration 
of many years (unless the disease is due to a rapidly growing 
tumor) is not very satisfactory. There is no drug that will in- 
hibit the increased secretion of the pituitary, and if it is caused 
by a cystic growth, a sarcoma or other malignant tumor, it will 
rapidly progress to a fatal termination. If the disease is not 
caused by a malignant growth, and death is not caused by 
some intercurrent acute illness, the patient dies asthenic, 
with very low blood-pressure and failing heart. In the be- 
ginning of giantism and of acromegaly the operation to remove 
a portion of the anterior lobe would seem justifiable, especially 
as the splendid technique offered by Cushing has made the 
operation possible. Recently radiotherapy has been tried on 



452 THE PRINCIPLES OF THERAPEUTICS 

pituitary growths, and this may be a successful method of 
treating the condition. It certainly should be tried before oper- 
ation is deemed advisable. 

In the more or less advanced stages of acromegaly the anterior 
portion of the pituitary is probably not hypersecreting, but may 
even be subsecreting, and the posterior lobe is generally not 
secreting normally, as shown by low blood-pressure and an in- 
creased tolerance to sugar. In this condition the administra- 
tion of whole pituitary gland extracts improves the patient, may 
relieve the headache, increase the blood-pressure and heart tone 
and the muscle strength. If severe headache and cerebral 
symptoms are caused by cerebral pressure decompression may be 
done, or more radical surgical procedures would seem advisable. 

As previously stated, many of the symptoms of acromegaly 
are due to associated disturbances of other endocrine glands, 
especially the thyroid and the gonads, probably frequently the 
parathyroids and the suprarenals, and not infrequently the 
thymus has enlarged and renewed its activity. As in all dis- 
turbances of the central nervous system and especially in dis- 
turbances of calcium metabolism, the administration of an 
extra amount of calcium in the form of milk or the lactate or 
glycerophosphate of calcium diminishes the nervous irritability. 

Hyposecretion. — When the anterior lobe secretion is deficient 
in young children infantilism occurs, i.e., bone growth is inter- 
fered with, and the child remains small. If this secretion is in- 
sufficient at the adolescent period the hair does not grow in the 
axillae and on the pubis, the genitals remain infantile, and the 
child does not develop. Also there is more or less pigmentation 
likely to occur on the body which is probably due to coincident 
suprarenal disturbance. In these conditions although small 
doses may stimulate growth somewhat, treatment with pitui- 
tary extracts is not very satisfactory, and Goetsch has shown 
that large doses of pituitary fed to animals will inhibit growth, 
and feeding posterior lobe extract retards the development of 
the sexual glands. With hyposecretion of the pituitary there 
is testicular atrophy, and males assume the feminine type, and 
after castration eunuchs grow large and fat, showing an associ- 
ated disturbance of the pituitary secretion. 



PITUITARY GLAND 453 

Hydrocephalus may accompany hypopituitarism, and as- 
sociated with it there may be adiposity and sometimes genital 
abnormalities. So-called juvenile obesity is due to hypo- 
secretion of the pituitary, and these children are large, fat, 
have protuberant abdomens, scanty development of hair, small 
genitals, sometimes dry skin, and frequently are not mentally 
bright. 

X Hyposecretion of the posterior portion of the pituitary in 
older individuals may cause an abnormal development of fat 
deposited on the parts that are typical of Dercum's disease, 
adiposis dolorosa. This condition is probably caused by an 
associated disturbance of the thyroid gland. 

Cushing thinks that the increase in weight in subhypophy- 
seal secretion may be due to the coincident disturbance of the 
testicles or ovaries, and he also thinks that the islands of -Langer- 
hans in the pancreas may be disturbed and be a cause of the 
glycosuria sometimes seen in these subpituitary cases. 

In the cases of slightly lessened secretion of the pituitary 
there often are symptoms not much dissimilar to those caused by 
a large amount of adenoid tissue in the nasopharynx, and fre- 
quently it has been noted that when these adenoids are re- 
moved the child begins to normally grow. Hence it is suggested 
that the adenoids in the nasopharynx may have something to 
do with the disturbance of the pituitary. In old age this gland, 
as many other glands, seems to atrophy. 

There may be a hyposecretion of one part of the pituitary 
and at the same time a hypersecretion of the other part of the 
gland; or both portions may have a disturbed secretion. There 
may even be acromegaly from dysfunction without enlarge- 
ment of the gland. Hence the function of the pituitary cannot 
be determined by an x-ray picture outlining the size of the sella 
turcica, and a small sella turcica does not necessarily show that 
the pituitary is insufficient. Also it should be noted that growths 
or disturbances in other parts of the brain may cause dysfunc- 
tion of the pituitary without any sella turcica evidence. 

The typical evidences of subsecretion of the hypophysis, 
termed Frohlich's syndrome (dystrophy adiposogeni talis) are 
deposits of fat on the hips, on the sides of the thorax, over the 



454 THE principles or therapeutics 

pubis, scanty growth of hair everywhere except on the scalp, 
small genitals, in girls and women after maturity absence of 
menstruation, lack of sexual desire in both sexes, soft skin, 
lowered temperature and sometimes polyuria and thirst. There 
may be headache, drowsiness, loss of memory, and even more 
serious cerebral disturbances. Sometimes fat is deposited on 
the hips, thighs, and abdomen, and occasionally in women there 
is an increased amount of hair growth. 

There is likly to be digestive disturbances, subnormal tem- 
perature, low blood-pressure, and, as Plummer has shown, a 
lowered basal metabolism. Sometimes these patients develop a 
cachexia and die asthenic, as in acromegaly. 

Sometimes dysfunction of the pituitary causes hypertension, 
a slow pulse, and some exophthalmos, but it should be constant- 
ly borne in mind that it is very rare that the symptoms present 
are due to disturbance of only one of the endocrine glands, as the 
interrelations are so close that the disturbance of one causes 
dysfunction .of others. 

Uses.— The administration of pituitary extracts for disturb- 
ances of the secretions of the gland have not been very success- 
ful. Not infrequently, however, pituitary headache is cured by 
the administration of extract from the whole gland. If the 
patient is stout and is a woman, and amenorrhea is also a symp- 
tom, the combination of thyroid and pituitary treatment is very 
successful, unless the headache is due to a tumor. It has been 
stated that posterior lobe extracts would increase the mammary 
secretion, but this has not stood the proof of test. When 
administered by the mouth, instead of increasing the blood- 
pressure, it may occasionally cause some depression, loss of 
heart strength, and if long given, emaciation. These symptoms 
may develop because these extracts are likely to contain 
large amounts of extracts of nervous tissue or histamin. Abel 
and Nagayama 1 have found considerable histamin in commercial 
post-pituitary extracts. 

The administration of anterior pituitary has its greatest 
value in dystrophy adiposogenitalis, but such treatment is 
more successful if combined with appropriate thyroid treatment, 
1 Journ. Pharm. and Exp. Thera., Baltimore, June 1920, p. 401. 



PITUITARY GLAND 455 

and probably it is well in females to add ovarian extracts and in 
males testicular extracts to the treatment. 

The most important use of extract made from the posterior 
lobe (often termed infundibular extract) is in obstetrics. For 
this purpose it is always given hypodermatically in doses of J^ 
to 1 mil. The drug has been used too frequently, as it may 
cause asphyxia of the child or rupture of the uterus. It should 
never be used unless the cervix is completely dilated and there 
is no obstruction to the free passage of the child through the 
pelvis, and it may always be advisable to administer an anesthet- 
ic as the head of the child is passing over the perineum, if the 
contractions of the uterus have been increased by the pituitary 
injected. Infundibular extracts should not be used in normal 
labor, and perhaps never should be used in a primipara, and the 
dose should be small in a multipara. Under its action the 
uterine contractions are brisk and frequent, and unless the child 
is rapidly born it becomes asphyxiated from interference with 
the placental circulation. In post-partum hemorrhage this 
preparation is not as valuable as is ergot. 

Pituitary extracts administered by the mouth have some- 
times been given in menorrhagia or metrorrhagia, but they are 
not as efficient as ergot unless pituitary disturbance is a cause 
of the bleeding. If there is no evident cause for menorrhagia 
or for too frequent menstruation in young girls, mammary 
extract represents the best treatment, although if the girl shows 
signs of pituitary disturbance a combination of these two 
glandular extracts will be of greater value. 

In conditions of cardiac failure and in shock with low blood- 
pressure and whenever there is dangerous low blood-pressure 
extracts of the posterior lobe given hypodermatically in 1 mil 
doses is of benefit. It acts less rapidly than epinephrine 
preparations, but its action is much more prolonged. It also 
has an advantage in these conditions of promoting activity of 
the kidneys. 

After abdominal operations when normal intestinal peristalsis 
is not present and there is a tendency to tympanites pituitary 
extracts given hypodermatically are of great value. One mil 
may be injected hypodermatically every twenty-four hours 



456 THE PRINCIPLES OF THERAPEUTICS 

for two or three days, and then less frequently until normal 
tonicity of the intestine has returned. If from the paralysis 
of the intestines gas is pressing on the diaphragm and interfering 
with the heart, a second dose of the hypophysis preparation may 
be given within a few hours after the first. 

If after a laparotomy or after parturition the bladder does 
not act and is semi-paralyzed, pituitary injections are of 
benefit. It is also of value, both when given hypodermatically 
and by the mouth, in incontinence of urine both in adults and in 
children, and it sometimes acts very satisfactorily in nocturnal 
incontinence. 

In diabetes insipidus which seems so frequently due to hy- 
pophysis disturbance, hypodermatic injection of posterior lobe 
extracts often act almost as a specific, causing the output of 
urine to be decreased, the urine to be of higher specific gravity, 
and thirst to be stopped, and at the same time the headache 
which so frequently accompanies this condition ceases. This 
preparation or any preparation of the pituitary will not have 
this satisfactory action if given by the mouth. Also this 
treatment, even hypodermatically, does not cure the condition 
unless the pituitary becomes normal in its activity; con- 
sequently the injections must be repeated. 

Some vasomotor disturbances may be due to dysfunction of 
the pituitary, and neuralgias, weariness and muscular weakness 
may be due to such a condition, and may be helped by adminis- 
tering by the mouth extracts of the whole gland. When the 
mother, after parturition, does not gain her strength and is 
weak and miserable, there may be pituitary deficiency, and 
pituitary feeding, associated with other proper treatment will 
benefit her'. 

It is possible that some cases of epilepsy, especially in child- 
ren and youth, are due to dysfunction of the pituitary, probably 
associated with disturbed function of other glands, perhaps 
more especially of the parathyroids. In appropriate cases 
administration of preparations of the whole gland should be 
tried. 

Even when pituitary preparations seem positively indicated, 
if extracts of the whole gland are long given there is likely to 



PITUITARY GLAND 457 

be an increase in the formation of uric acid, and joint pains may 
occur. Consequently the results of such treatment should be 
carefully watched. 

The exact cause of rickets is still not known, although it is 
apparently a mistake of nutrition, but probably not entirely one 
of privation. It has not been shown that disturbance of the 
thymus gland is related to rickets. It also has not been shown 
that disturbance of the anterior lobe, of the pituitary body is a 
cause of rickets, but it is a fact that this portion of the gland is 
closely related to the formation of solid bone. Consequently, 
in the disease of rickets, besides administering cod liver oil and 
phosphates and good nutritious food, anterior pituitary extract 
should be tried. 

Administration. — The official Hypophysis Sicca is prepared 
from the posterior lobe of the pituitary body of cattle. It 
occurs as a yellowish or grayish powder, which is only partially 
soluble in water, and the dose is 0.03 Gm. (J^ grain). The 
official preparation Liquor Hypophysis is a solution containing 
the water soluble principle or principles of the fresh posterior 
lobe of the pituitary body of cattle. It occurs as a transparent 
liquid, the dose of which is 1 mil (15 minims). As hypophysis 
solutions are generally used hypodermatically only, this prepara- 
tion is hardly necessary, as sterile ampules are better. These 
ampules are made in two strengths, and contain % mil or 1 mil of 
diluted posterior lobe extract. Tablets made from the posterior 
lobe may be obtained, each representing }{ q of a grain of its 
active principles. When administering these posterior lobe 
preparations symptoms of depression may develop. Conse- 
quently the patient should be carefully watched during such 
treatment. 

Preparations of the whole gland may be obtained, also prep- 
arations of the anterior lobe. Tablets of the anterior lobe 
represent 2 grains of the gland, and tablets of the whole gland 
may be obtained that represent 1 grain. These preparations 
also may be obtained in powder form. The frequency of the 
dose of any of these preparations depends upon the rapidity of 
the action desired. Generally the condition is chronic, and 
one or at most two daily doses are sufficient, and when the 



458 THE PRINCIPLES OF THERAPEUTICS 

minute amount of the secretion of this gland that circulates in 
the blood daily is considered, it will be seen that the dose to be 
administered should be small. 

SUPRARENAL GLANDS 

Description. — Besides the adrenal glands, which are situated 
over the kidneys, there is likely to be small supernumerary 
suprarenal tissue scattered along the spermatic vessels in the 
male, on the broad ligaments in the female, and in various 
parts of the abdomen. Just how active this supernumerary 
suprarenal tissue may become after the adrenal glands have 
been destroyed has not been determined, although they may 
hypertrophy. 

The adrenal gland is composed of the cortex and the medulla. 
The cortex is embryologically related to the genital system and 
as far as its function is understood, this portion of the adrenal 
glands is closely related to the development of the sexual organs. 
Macleod notes that the evidence of such relationship is 
shown by the fact that with sexual precocity there is hyper- 
trophy of the adrenal cortex, that it is hypertrophied during 
pregnancy, and that it is poorly developed in sexual defi- 
ciency. The medullary portion is composed of masses of cells 
richly surrounded by blood. In these cells are character- 
istic granules which stain readily with chromic acid and are 
termed chromaffin cells. The medullary portion of the adrenal 
is embryologically related to the sympathetic nervous system. 

Function.— Animals may survive without the medullary 
portion of the glands, but complete extirpation of the adrenal 
glands is fatal to most animals. The symptoms begin on the 
second day after extirpation, and are • weakness, both of the 
muscles and of the circulation; lowered temperature; dyspnea; 
and finally convulsions and death. If one-eighth of the total 
amount of the gland is retained the animal may survive, but 
transplants of adrenal tissue and the feeding of suprarenal 
extracts are not life-saving, according to Macleod. 

Shafer and Oliver first showed that there was a blood- 
pressure-raising principle furnished by the suprarenals. This 
principle is produced in the medullary portion of the gland, and 



SUPRARENAL GLANDS 459 

is variously known as epinephrine (Abel's name) suprarenin, 
adrenin, and adrenalin. This principle has been obtained in 
crystalline form, and chemically is closely related to tyrosine. 
Epinephrine is chemically an amino acid derivative, and may be 
made synthetically. Injection of minute doses of epinephrine 
will cause a rise in blood-pressure, due to the constriction of the 
arterioles, and will slow the pulse, due to action on the vagus 
center. The vessels of the splanchnic area are most influenced 
by epinephrine, but the large vessels near the heart are not 
much affected on account of the absence of muscular tissue, and 
the coronary vessels have been thought not to be contracted in 
most animals. With large doses dilatation of the vessels instead 
of contraction is caused, and dilatation at times rapidly follows 
constriction and may be dangerous. There may be a slight 
dilatation of the pupils when an epinephrine solution is applied 
to the eye. The salivary glands and the mucous glands of the 
mouth and pharynx are stimulated by it, and epinephrine, when 
injected, disturbs the glycogen function of the liver so that 
hyperglycemia and glycosuria occur. 

Herter and Richards were the first to note the relationship 
of the suprarenals to glycosuria, and from their investigations 
and those of others we must conclude that perfect glycogenic 
function depends upon the proper relation between the secretion 
of the suprarenals, the secretion of the pancreas, and the function 
of the liver, and if any one of these three organs is disturbed, 
sugar may appear in the urine. If too much epinephrine secre- 
tion reaches the blood, glycosuria is likely to occur, appar- 
ently due to a stimulation of the liver to increase its output 
of glycogen. 

An extra amount of glycogen in the blood (if not too much) 
is a stimulant to muscle energy, and the whole body is stimu- 
lated. The glycogen function of the suprarenals is largely under 
the control of the nervous system and is related to the pituitary 
secretion. Stimulation of the thyroid may cause a stimulation 
of the adrenal glands, the reason that so frequently in Graves' 
disease there are evidences of hyperadrenalism. 

The suprarenal glands are seriously affected in toxemias, 
whether the toxemia is caused by infecton or by the absorption 



460 THE PRINCIPLES OF THERAPEUTICS 

of poisons from some focus within the body. Prolonged infec- 
tion exhausts the suprarenals and causes the depression and 
shock so frequently seen in serious illness, and repeated toxemias 
completely prostrate, so to speak, the adrenal glands. On this 
account coal-tar or other depressant drugs should not be given 
in prolonged illness, and not at all in a condition that soon 
leads to depression. This is typically true in influenza, and 
many a patient is seriously, if not fatally, injured by adding 
coal-tar or aspirin depressants to the prostrating infection of 
the influenza germ. Pneumococcic infection and the toxins of 
diphtheria are also depressant to the adrenals. Insufficient 
adrenals at any time cause the patient to have a weakened de- 
fense against any infection. v 

Although it has lately been concluded that a continuous dis- 
charge of epinephrine from the adrenal glands is not necessary 
for the maintenance of normal blood-pressure, still when neces- 
sity calls for an extra rise in blood-pressure and extra energy, the 
adrenals immediately furnish the needed extra secretion which 
for a time causes contraction of the abdominal vessels and raises 
the blood-pressure. 

Meek 1 suggests that the cortex of the adrenals may supply a 
hormone necessary for life by virtue of its maintaining muscular 
and vascular tonus, and that the medullary portion supplies a 
particularly active pressor substance, epinephrine, to be used in 
times of emergency, and as a general body stimulant. In the 
vasomotor disturbances there is generally suprarenal insuffi- 
ciency, and a patient who faints easily has an insufficient epi- 
nephrine secretion. This type of patient is readily shocked. 

Sergent's test of adrenal sufficiency, by noting the color by 
gently stroking different parts of the body, is difficult to read in 
border-line cases, and as the color varies so in different parts of 
the body, it is not a test of any great importance, especially as 
it depends so much upon the character of the skin, the method 
of stroking, and whether, or not, there is a tendency to urticaria. 

Pigmentations on the body tend to show that the suprarenals 
are in trouble, and that they will soon become insufficient, unless 
the cause of their irritation is removed. Lowered suprarenal 

Endocrinology, July-Sept., 191 7, p. 305. 



SUPRARENAL GLANDS ' 46 1 

activity may cause hyper chlorhydria, with heart-burn and pyro- 
sis. This condition is often seen in low blood-pressure, in cases 
of depression, and in old age. 

It has been thought that the adrenals assist in rendering 
harmless some of the products of muscular activity, and when 
these glands are insufficient, toxemias more readily occur. 
This detoxicating function seems to be present in several of the 
internal secreting glands, especially in the thyroid and parathy- 
roids, and, if these glands are not properly functioning, certain 
metabolic substances may cause serious symptoms, though 
while they properly function these same substances are inocuous 
and harmless. 

In 1855 Addison first pointed out the relation between the 
disease characterized by darkening and bronzing of the skin, 
anemia, digestive disturbances, and a pathologic condition 
of the suprarenal glands, since which time it has been recognized 
that the cause of so-called Addison's disease is a disturbance of 
the suprarenal glands that prevents their normal function, per- 
haps most generally a tuberculous condition. 

Lately it has been shown by Voegtlin and Macht that a pres- 
sor substance, not the epinephrine substance of the medulla, can 
be obtained from the suprarenal cortex. This may be the 
substance that is needed to maintain normal blood-pressure 
while the more active pressor stuff of the medulla is reserved 
for emergencies. Also in the cortex there is a large amount of 
lipoids. 

Hyperadrenalism.-^Reasoning from analogy as the thyroid 
is known to hyper- and hypo-secrete and cause consequent con- 
ditions, we can but presuppose that the adrenal glands, next 
in importance to the thyroid, must hyper- and hypo-secrete, 
and, also have various modifications of secretion and dys- 
function. 

There can hardly be a doubt that certain individuals have 
continually a hypersecretion of these glands. Just what rela- 
tion hyperadrenalism has to abnormally high blood-pressure, 
the opposite condition seems to be a fact, namely, that sub- 
secretion of the adrenals causes low blood-pressure. Drugs 
that are known to stimulate the adrenals, as strychnine, raise 



462 THE PRINCIPLES OF THERAPEUTICS 

the blood-pressure. Repeated exertion and properly graded 
athletics raise the blood-pressure, especially the systolic pres- 
sure. Also from increased muscular activity more or less 
hypertrophy of the heart is caused. But an individual cannot 
be strong and sturdy and full of energy and muscular activity 
without sufficient adrenals, and very strong individuals who are 
well balanced mentally and can withstand pain, shock, blood- 
letting, injuries, infections and toxemias, all have a sufficiency 
of adrenal secretion, if not an increased amount. 

An abnormal secretion of the adrenals may have something 
to do with the unknown pathogenesis of gout, as in this disease 
there is some disturbance of the nitrogen metabolism, though 
various organs may partake in the causation of that disease. 
An increased suprarenal activity seems to be associated with an 
increased uric acid output. 

Hyper-function of the adrenals may be one of the causes of 
large appetite, good digestion, and splendid alimentation. 
Certainly, deficiency of the adrenals causes a disturbance of the 
secretions of the gastrointestinal tract, imperfect peristalsis, 
and imperfect sexuality. 

If there is hypersecretion of the adrenals early in life there 
is likely to be an early development of puberty; a girl may 
develop menstrual flow and have pubic and axillary hair, even 
when four or five years of age, and a boy of the same age may 
show the sexual development of full puberty, have hair on the 
body, have a mustache, and a masculine voice. If the hyper- 
adrenalism continues in the case of the female, the girl may show 
masculine characteristics. 

Thyroid hyperactivity increases the kinetic drive, so termed 
by Crile, and this, added to the present age of nervous, restless 
push, causes brain tire and heart tire. Also, as Crile states, 
emotion, energy and excitement increase the secretion of 
epinephrine, and that substance activates the muscles and 
increases the circulatory tone. If this stimulation persists, 
there can be only ultimate suprarenal tire and suprarenal 
insufficiency, and with this insufficiency must come weakness 
and debility. 

Chronic focal infection can at first irritate the suprarenals 



SUPRARENAL GLANDS 463 

and stimulate them to extra secretion, to be followed later by 
subsecretion. On the other hand, toxins from certain germs not 
only of the acute infections, such as diphtheria, influenza and 
pneumonia, but from some chronic focal infections, can inhibit 
the secretion of the suprarenals from the start. These toxins 
can affect the suprarenals, either to stimulate or to inhibit 
their activities, whether the infection is in the abdomen or in 
the mouth. Tonsillar infection and tooth infection can cause 
increased or decreased blood-pressure, and removal of such 
infection can correct the condition. Glycosuria may be caused 
by mouth infection. Whether such infection stimulates the 
adrenals to an extra output of epinephrine, which in turn urges 
the liver to elaborate too much glycogen, or whether the 
infection disturbs the thyroid or the pituitary or the pancreas, 
or all of these glands, nevertheless glycosuria is sometimes the 
result, and the removal of the focal infection will very many 
times cure the glycosuria and prevent the development of 
diabetes mellitus. 

Mental depression, sorrow, and melancholia all inhibit the 
efficiency of the suprarenals, while, as Crile says, joy and 
hope seem to be a stimulant to these glands. Also insufficiency 
of the thyroid with the depression that goes with that condition, 
can but, at times, inhibit the suprarenals. The suprarenals are 
inhibited in their activity by acute pain though lasting but a 
short time, by subacute pain lasting a longer time, and by chronic 
pain lasting a still longer time, as evidenced by lowered blood- 
pressure, weakened heart action, and more or less shock. 

The necessity for suprarenal secretion directly reaching 
the blood is shown by death being caused by tying of the veins 
of the adrenal glands, although death will not occur as rapidly 
as after extirpation of the glands. 

Hypoadrenalism. — There are all grades of subsecretion of the 
adrenals, from complete absence of secretion from destruction 
of the adrenal glands (as occurs in the final stages of tuber- 
culosis of these glands in Addison's disease) to an almost 
unrecognizable subsecretion. A mild form of hyposecretion is 
shown by lack of muscle tone, low blood-pressure, cold extremi- 
ties, proneness to infections, slow recovery from acute disease, 



464 THE PRINCIPLES OF THERAPEUTICS 

weak heart action, poor digestion, poor appetite, constipation, 
lack of sexual tone, weariness, and the condition termed 
neurasthenia. Some of these conditions may be prominently 
present and others may be only slightly in evidence, but they 
all show more or less insufficiency of the suprarenal glands. 

Still greater insufficiency of the adrenals is shown by diarrhea, 
nausea, vomiting, and slight pigmentation of the skin. Small 
pigmentations developing at any time, or especially as age ad- 
vances, probably shows adrenal insufficiency. Brown spots on 
the body, not due to liver disturbances, will disappear under the 
administration of suprarenal extracts. 

When Addison 's disease is in evidence the patient may die of 
the acute disease within a short time without any pigmentation 
whatever, but in chronic, slowly developing Addison's, pig- 
mentation of the body occurs, sometimes bronzing to the extent 
of changing a white person to a black one, so that he could not 
be distinguished from a negro by his color. Even the mucous 
membranes are pigmented, the mouth, the tongue, the nostrils, 
and, in the case of women, the vagina. There may remain 
white patches on certain parts of the body, but in some cases 
this pigmentation may cover practically the whole body, and it 
is a fact that the administration of suprarenal extracts fre- 
quently will remove this pigmentation, even if it does not save 
life. Patients with Addison's syndrome are anemic; have a 
very low systolic blood-pressure, even to 95 ; have very weak 
heart action with consequent dyspnea; have complete insuffici- 
ency of the digestive glands, and many times abdominal pain. 

Occasionally Addison's disease has not shown apparent 
disease of the adrenals, but there probably has always been 
some nervous disturbance or some circulatory disturbance of 
the adrenal glands; but there is probably no doubt that with 
these symptoms, namely, bronzing, anemia, low blood-pressure, 
and digestive symptoms, the adrenals are always subsecreting. 
The cases in which the adrenal glands are not permanently 
diseased and have only lost their function are probably the ones 
that are more or less permanently benefited by the feeding of 
adrenal gland tissue or extracts. If both glands are tuberculous 
and not sufficient healthy tissue remains to be stimulated or to 



SUPRARENAL GLANDS 465 

cause suprarenal function, or if there are not supernumerary 
glands that can assume such function, feeding of suprarenal 
extracts may help, but will not save the patient. 

Hemorrhage into the suprarenals has caused sudden death, 
similar to shock. Also the adrenal glands can develop an 
acute inflammation, probably not recognizable. Occasionally 
cancer or sarcoma will affect a suprarenal gland, and sometimes 
both glands. 

Disturbance of the suprarenals sometimes causes asthmatic 
attacks, frequently associated with other signs of protein 
poisoning, and these patients are benefited by the administra- 
tion of suprarenal. 

Disturbances of the suprarenals are at times the cause of 
mental peculiarities. A hypersecretion may cause the indivi- 
dual to be aggressive, and women to assume a more or less 
masculine type. Subsecretion may make the individual cranky, 
dissatisfied with everything, probably because he always feels 
below par and inefficient, and never feels normally fit. 

Uses. — Charles E. DeM. Sajous, 1 who has done so much re- 
search on the adrenal glands, rightly asserts that some of the 
sudden deaths seen in soldiers after violent exertion, without 
apparent heart lesion, is due to hypoadrenia; and it has been 
shown that although the heart may be normal and even en- 
larged and ready to do extra work, very small adrenals prevent 
the possibility of severe muscular strain, and such individuals 
fall, faint, are prostrated, or may even suddenly die after hard 
exertion. Sajous states, as has long been known, that digitalis 
is of no benefit in this kind of circulatory weakness, while supra- 
renal gland is at times of benefit, and, if o.ooi Gm. (% grain) 
of epinephrine, dissolved in physiologic saline solution, is in- 
jected hypodermatically, it may save life in these shocked cases. 
Later suprarenal gland extracts may be given by mouth, daily, 
with benefit. 

Sajous also emphasizes what Crile has also stated, that pro- 
longed excitement, fear, rage, and the general strenuosity to 
which a soldier in active warfare is subjected may use up his 
reserve adrenal secretions, and the medullary portion of the 

1 Perm. Med. Journ., Jan., 1919, p. 215. 
30 



466 THE PRINCIPLES OF THERAPEUTICS 

adrenals become insufficient, and he suddenly becomes weak- 
ened or shocked. This probably represents an important cause 
of the "shocking" of soldiers, and explains the considerable 
length of time necessary for them to build up their reserve 
secretion and become again physically fit. 

In all shocked conditions from injury, in prostrating acute 
infections such as dysentery, typhoid fever, and especially in 
diphtheria, pneumonia and influenza, the adrenals have become 
insufficient, and from infections they may become actually 
pathologically disturbed. There may be hemorrhages into the 
glands. In all these cases suprarenal extracts should be given, 
but in not too large doses, as a secondary fall of pressure may 
occur; also large doses have caused death. Rest, heat, suprare- 
nal feeding, and strychnine in not too large doses is the treat- 
ment. Of course the blood-pressure-raising properties of 
caffeine and atropine may be needed to tide over the condition, 
but the cure is brought about by the administration of suprare- 
nal, or by the return of the adrenals to normal secretion. 

While part of the neuro-circulatory asthenia of enlisted men 
is due to thyroid hyperactivity, part is also due to suprarenal 
insufficiency. Rather typical of adrenal insufficiency are cold 
hands and feet, and bluing of the lips on the least exertion. 
Although it has been shown that epinephrine secretion does not 
seem necessary for the maintenance of normal blood-pressure, it 
is very necessary to develop an increased blood-pressure when 
the pressure is subnormal and the circulation insufficient. 

The rise in blood-pressure after the administration of epineph- 
rine, when given on the tongue or hypodermatically, or when 
it is absorbed from mucous membranes other than the stomach, 
quickly occurs, but it does not last long. This action is not, 
however, the action that causes the greatest help ; it is the stimu- 
lation that it causes to the suprarenal glands. A blood-pressure 
raising treatment that lasts such a short time could be of onljr 
momentary help, consequently, as soon as the emergency is past, 
after administering epinephrine hypodermatically or on the 
tongue (though such treatment may be repeated a few times, 
especially on the tongue) , the greatest advantage from supra- 
renal treatment is obtained by giving the whole gland extracts. 



SUPRARENAL GLANDS 467 

by the mouth. When given in tablet, the tablet should be 
crushed and swallowed with water. The blood-pressure-raising 
substance seems to be changed chemically in the stomach, so 
that it does not cause the usual rise of arterial pressure, but the 
rest of the gland seems to stimulate and help a depressed circu- 
latory condition. Also, as above stated, in Addison's disease 
with pigmentation administering the chromaffin part of the 
glandular substance either directly causes a diminution of the 
surface pigmentation, or else it stimulates the adrenal glands 
to furnish the substance which is lacking. The gland by the 
mouth is active, as the author has seen pigmentation disappear 
and a blackened skin become white, when the suprarenal glands 
were later found, after death, to be riddled with tuberculous 
disease. 

Too much epinephrine given hypodermatically or on the 
tongue, may cause a low blood-pressure and a serious disturb- 
ance of the respiratory center. The treatment of such over- 
action would seem to be atropine and caffeine hypodermatically, 
and artificial respiration. Suprarenal extracts often stimulate 
the heart to better activity. After injection of epinephrine the 
first rise in blood-pressure may be soon followed by a fall to, 
often, be followed by a second slight rise. 

Development of the genitalia, especially of the testes, may 
be stimulated by the administration of suprarenal, and at times 
sexual precocity in young children has been shown to be asso- 
ciated with disturbances causing hypersecretion of the adrenal 
cortex. In these young children who have this abnormal 
sexual development it has been generally found that there was 
a growth of the adrenal cortex, most frequently, perhaps, a 
hypernephroma. In milder forms of hypersecretion of the 
adrenal cortex in children there is a more rapid development 
than normal of the pubic hair and of the external sexual organs. 
This condition more frequently occurs with females than with 
males. 

It is impossible to decide what relation the suprarenal glands 
have to high blood-pressure which is so much in evidence to-day. 
There is no justification for removing the suprarenal glands for 
such a condition at the present time, because the exact relation 



468 THE PRINCIPLES OF THERAPEUTICS 

of constant high pressure to the suprarenals has not been 
proved. X-ray treatment of these glands has been suggested, 
but such treatment seems of doubtful value, as it would be im- 
possible to treat these glands without treating other parts of 
the abdomen or back, probably to the disadvantage of other 
organs. 

Serious burns of the body have sometimes caused adrenal 
insufficiency and hemorrhage into the tissues of the glands. 
Seriously burned, as well as other shocked patients, therefore, 
should receive suprarenal extracts. 

It has been shown that patients who have the morphine habit 
have insufficiency of the suprarenals, and that they are also 
more susceptible to all kinds of poisoning. It has also been 
experimentally shown that any insufficiency of the suprarenals 
increases the susceptibility to poisoning. 

Chloroform and ether anesthesia more or less inhibit the 
output of the suprarenals, and depression following anesthesia 
is well treated by suprarenal and pituitary extracts. 

Associated with Bright's disease there may be stimulation of 
the suprarenals, and this may be a cause of the increase of 
blood-pressure besides what is caused by the abnormal amount 
of irritants in the blood. 

Just what is the relationship of tobacco to the suprarenals has 
not been determined, especially as nicotine has been shown by 
Stewart and RogofT 1 to inhibit the epinephrine output of the 
suprarenals. Certainly, men who are used to smoking have 
their blood-pressure raised by tobacco, but the excessive use of 
tobacco does cause low blood-pressure and weakening of the 
circulation. This has been supposed to be due to action on the 
heart muscle, but as these experimenters state, it may also be 
due to inhibition of the epinephrine output, and therefore to a 
lack of tone of the splanchnic vessels. 

In any condition of low blood-pressure, depression and* cir- 
culatory weakness whether suprarenal will be of benefit, or not, 
cannot always be determined before the clinical trial. If there 
are other symptoms of adrenal insufficiency, suprarenal feeding 
is often of value, but in ordinary fatigue and in low blood- 

x Journ. of Pharm. and Exp. Thera., June, 1919, p. 183. 



SUPRARENAL GLANDS 469 

pressure from many conditions, the treatment is very dis- 
appointing. 

Many times with indigestion of a functional type suprarenal 
helps the patient and corrects the condition. It has not been 
determined why hypersecretion and hyposecretion of the thy- 
roid cause so many gastrointestinal disturbances, but the in- 
terrelations of the endocrine glands should always be kept in 
mind. Certain it is that sufficient suprarenal secretion seems 
necessary for normal gastrointestinal digestion, and adrenal 
extracts are sometimes especially valuable in weak muscle 
activity of the stomach and intestines. 

In Addison's disease there may be periods of intermission, 
therefore when suprarenal extracts have been given and im- 
provement occurs such improvement may not be due to the 
treatment. However, it seems to be a fact when the suprarenal 
glands are not too seriously injured that there is some improve- 
ment from feeding suprarenal extract, and naturally the whole 
gland must be given, the administration of epinephrine rep- 
resenting only a small part of the activities of the adrenals. It 
should be given for a long time, a small dose once a day. Al- 
though some symptoms are improved by such treatment, 
especially the pigmentation on the skin and mucous membranes, 
if the adrenal glands are seriously diseased this treatment cannot 
save life. Pituitary extracts in small doses may be added to the 
suprarenal treatment, as pituitary extract is known to stimu- 
late the adrenals. If the patient is benefited by these glandu- 
lar treatments, there is a rise in blood-pressure, a better cir- 
culation, and an improvement in digestion and nutrition, and, 
as just stated, the pigmentation disappears. 

The value of suprarenal and especially of epinephrine in 
asthma has now long been noted. An epinephrine tablet 
crushed with the teeth and allowed to absorb from the mouth, 
or 5 to 10 drops of an epinephrine solution of 1 part to 1000, will 
usually stop an asthmatic attack. Also, the solution has been 
sprayed directly into the larynx with success. Large doses of 
epinephrine intravenously or hypodermatically have caused 
death. Not every patient, however, is helped by epinephrine 
treatment, some patients are more benefited by nitroglycerin. 



470 THE PRINCIPLES OF THERAPEUTICS 

It is not always possible to foretell which patient will be im- 
proved by which method of treatment, as the two treatments 
are opposed to one another. Theoretically, if the blood-pres- 
sure is high, nitroglycerin would be the treatment; if the blood- 
pressure is low, adrenal or epinephrine preparations would be 
the treatment. There has seemed to be some relation between 
disturbances of the suprarenal glands and asthma, and perhaps 
the adrenals are disturbed in various anaphylactic reactions, 
especially in those that are associated with shock, and asthma 
many times represents an anaphylactic reaction. Rarely, 
however, is suprarenal treatment a cure for asthma, even if it is 
successful in stopping the paroxysms. The cause of the asthma 
must be sought and treated. 

It has been suggested that a dose of epinephrine, to be ab- 
sorbed from the mouth, should be given before the intravenous 
injection of arsphenamine, as tending to prevent some of the 
unpleasant symptoms that may follow such an injection. The 
dose should be given an hour before the injection, and then per- 
haps another dose just before the intravenous injection is given. 

Auer and Meltzer 1 have shown experimentally that there is a 
more lasting blood-pressure-raising effect from epinephrine if it 
is given intraspinally. This would seem to be a valuable sug- 
gestion for trial in every shocked condition that did not react 
to other methods of treatment. Sajous 2 advises that in acute 
shock and in heart failure (acute adrenal failure he terms it) 
during an acute infection hypodermic injections be given of 10 
minims of a i to iooo epinephrine solution, in a syringeful of 
saline solution, every two hours for three doses, and then four 
times daily, if needed. 

In morphine and opium poisoning when artificial respiration 
is apparently saving life, many times death is finally due to 
heart failure. Therefore, if the pulse is not good, or at any 
time becomes feeble in such poisoning, epinephrine solutions 
on the tongue, hypodermatically or intraspinally, should be 
considered. 

Suprarenal sprays and snuffs have been used frequently in 

1 Amer. Journ. of Physiol., Dec. 1918, p. 286. 
2 Journ. Med. Soc. of N. J., No. 15, 1918, p. 109. 



SUPRARENAL GLANDS 47 1 

hay fever, and in the eye in certain inflammations, and locally 
to cause blanching of a part to prevent hemorrhage before minor 
operations ; it has, also, been sprayed into the throat or larynx, 
or swabbed over irritated regions of the tonsils or pharynx, to 
control acute congestions. The relief from shrinking of the 
tissues and a diminution of the swelling is very great, but unless 
used repeatedly, there is likely to be renewed swelling and, 
sometimes, a greater congestion than before. Occasionally a 
patient has considerable irritation from suprarenal sprays in 
the nose or mouth, such as serious sneezing and even pain. 
There is no habit formed from the use of suprarenal extracts. 

Epinephrine is added to different preparations of cocaine 
for local anesthesia, and renders the anesthesia more lasting, 
and the bleeding during the operation less. There may be a 
considerable rise in the blood-pressure from the use of epineph- 
rine solutions on the mucous membranes, but it should be 
remembered that the blood-pressure-raising substance is 
destroyed when the solution, tablets, or powders are taken into 
the stomach. 

The value of suprarenal in hemorrhagic conditions and 
purpura is not very great. Occasionally it has seemed to have 
been of some value, but other treatments are better. 

With patients who are neurasthenic and always have a low 
type of circulation, suprarenal may be of benefit, but it must be 
given for a long period, and unless there is good suprarenal 
tissue to be stimulated, any permanent success is doubtful. 
There seems to be no question that there are individuals who 
always have an insufficient secretion from the adrenals. 

Administration. — The official Suprarenalum Siccum (desic- 
cated suprarenal glands) is prepared from the glands Of animals, 
and should contain about 0.5 per cent, of epinephrine. It 
occurs as a yellowish powder, partially soluble in water and the 
watery solutions contain the active principle, epinephrine, and, 
therefore, are active locally in contracting blood-vessels. The 
Pharmacopceial dose of the powder is 0.25 Gm. (4 grains), but 
this dose is too large if the preparation is to be frequently 
repeated. However, the exact dose of suprarenal when 
administered by the mouth has not been determined. It 



472 THE PRINCIPLES OF THERAPEUTICS 

should not be taken on any empty stomach, as it may cause 
nausea. 

There are no good symptoms of over-administration such 
as are so readily noted when thyroid is administered, but an 
increase in blood-pressure, unpleasant thumping of the heart, 
and headache, indicate that too much has been given. If 
the patient is pregnant, suprarenal may cause uterine pains, 
hence if suprarenal is given for low blood-pressure during 
pregnancy its action should be carefully watched. 

Prolonged use of epinephrine has been thought to cause 
atheroma, but this occurrence must be very rare, as the drug is 
but seldom used for any great length of time, except in Addison's 
disease. 

Various epinephrine preparations may be obtained. The i to 
iooo solution is the most useful for administering it by the 
mouth and for use on mucous membranes. The action of these 
preparations is only on the circulation and is not suprarenal 
action. Ampules representing i part in 10,000 may be obtained 
for hypodermatic use. The dose of a 1 to 1000 solution on the 
tongue is 5 to 10 drops, diluted with only an equal number of 
drops of water, so that absorption will surely take place from 
the mouth, or a tablet may be crushed and dissolved in the 
mouth. Adrenalin tablets are offered which contain 0.001 Gm. 
per tablet. 

All solutions made from the dried gland or from the powder 
soon deteriorate unless some antiseptic is added. The ad- 
renalin chloride solutions contain a small portion of chloretone. 
There are various adrenalin ointments, inhalants, and tablets; 
also there are various epinephrine preparations and suprarenin 
preparations. When epinephrine solutions are used as a spray, 
the strength should be 1 part to 10 or 15 thousand, or even 
weaker. 

Tyr amine Hydrochloride. — Tyramine has been isolated from 
ergot, and also is made synthetically. Tyramine hydrochloride 
occurs as a whitish crystalline powder, is soluble in water, and 
may be used in a 1 to 10,000 solution. Its action is similar to 
that of epinephrine, but less powerful and less persistent. It 
produces a rise in blood-pressure, and may be used in shock and 



CORPUS LTJTEUM 473 

collapse, or as a local hemostatic. As, like ergot, it contracts 
the uterus, it has been suggested for uterine hemorrhage. It is 
not as active a uterine contractor as is pituitary extract, hence 
perhaps safer in parturition. The dose of tyramine hydro- 
chloride is about 0.02 Gm. (}i grain) given in solution. 

CORPUS LUTEUM 

Description. — This small glandular structure named corpus 
luteum by Malphigi, has a distinct function although it is part of 
another gland, the ovary. Its activities are very positive and very 
distinct from the activities of ovarian substance before the cor- 
pora lutea develop and from ovarian substance minus the corpora 
lutea, ovarian residue. This glandular tissue does not occur until 
just prior to menstruation, and before puberty the interstitial 
cells of the ovaries furnish all the gonadal secretion that the 
female child requires. At puberty the ovule, Graafian follicle, 
ripens and ruptures, and the corpus luteum is a consequence. 

Function. — There is a general consensus of opinion that one of 
the functions of the corpus luteum is to sensitize the uterus to 
make it ready for pregnancy and for the growth of the placenta. 
It is also thought that it determines menstruation, and it prob- 
ably is a promotor of sexual impulses and sexual desires. This 
little gland grows for about two and a half weeks after ovula- 
tion and then gradually degenerates, provided conception has 
not occurred. If the female becomes pregnant, the corpus 
luteum persists at full activity, apparently, for about two 
months and then begins to degenerate. Just what causes the 
degeneration of this body at this time is not known. 

The relation of the corpus luteum to menstruation has not 
been determined, but some hormone must stimulate or by its 
absence cease to inhibit, the development of the next ovule 
and the new corpus luteum, and it would seem that this little 
gland being so closely associated with the rhythm of menstruation 
must be the tissue that controls this function. On the other 
hand, something must inhibit ovulation during pregnancy and 
during lactation, and it has been suggested that the placenta in 
the first instance and the mammary glands in the second instance 
may furnish such hormones. 



474 THE PRINCIPLES OF THERAPEUTICS 

Abnormal persistency and disease of the corpus luteum seem 
to prevent the next menstruation, and an abnormal function of 
several corpora lutea seems to be the cause of irregular and 
abnormal menstruation and of sterility. 

It has been suggested that the cessation of the nausea of 
pregnancy at about the beginning of the third month is due to 
the secretion from the corpus luteum of pregnancy, which at 
about the end of the second month begins to degenerate and 
.possibly furnishes substances for absorption into the blood, 
.while previous to that time when it was developing it did not 
furnish such a secretion; therefore the nausea. Some obste- 
tricians therefore believe in feeding this gland during the nausea 
of early pregnancy, and, it has been claimed, with some success. 
Such an action of this gland, however, would seem almost 
paradoxical. Certainly, a substance that is known to be a 
gland and known to have function, and known to increase in 
size during early pregnancy, must have increased functional 
activity. Therefore such an interpretation of the cause of 
nausea and then its cessation does not seem logical. It should 
be noted that very many women after pregnancy are in better 
health than ever before, probably due to normal stimulation of 
the endocrine glands. 

It should be recognized that irritations and infection in the 
pelvic region may cause disturbances of the ovaries and corpora 
lutea similar to the disturbance caused other glands closely 
associated with infections. With the many abnormal conditions 
that can occur in the pelvic region of women, it is not surprising 
that various disturbances of the ovaries, of ovulation, and, there- 
fore, of the corpora lutea, occur, and cause all kinds of over-secre- 
tion and under-secretion of these glands as evidenced by mental 
disturbances, by irregular, scanty or profuse menstruation, and 
by local pain. 

Just what relation the secretion of the corpus luteum of preg- 
nancy and the secretion of the placenta have to the growth of the 
breasts during pregnancy cannot be stated, but some hormones 
from some source cause the breasts to become ready for lactation. 
Sometimes the administration of corpus luteum extracts stops the 
pain in the breasts that occurs before and with menstruation. 



CORPUS LUTEXJM 475 

The relation of the ovaries and of the corpora lutea to the 
development of mammary cancer is of sufficient importance 
to deserve a most careful study. Mammary cancer is very 
frequent and generally develops at, or soon after, the menopause, 
i.e., at the time when the corpora lutea have ceased their func- 
tion and the ovaries are diminishing their secretion . Sometimes 
the removal of ovaries has stopped the growth of mammary 
cancer. There probably is some polyglandular disturbance at 
the period of the menopause which readily allows the mammary 
gland to become infected (if there is a germ of cancer) or to 
become stimulated to the production of small cells, if the growth 
is due only to rapid cell proliferation. 

The close relation of the mammary gland to menstruation 
and the corpus luteum function must be recognized, as the 
breasts always hypertrophy more or less just before and during 
every menstruation. It has also been suggested that perhaps 
the atrophy of the uterus at the time of the menopause furnishes 
some hormone that irritates the breasts. Although none of 
these questions can be answered, still the positive relationship 
is there, and the fact remains to be explained as to why the most 
frequent location of cancer in the female is in the breast, and 
the most frequent period of such a growth is after the 
menopause. 

Uses. — Corpus luteum extracts have been used with success 
in the delayed menstruation of young girls and in amenorrhea. 
If, however, it is thought that the ovarian secretion is insuffi- 
cient in young girls just prior to the age of puberty, ovarian 
extract, or perhaps better, ovarian residue, should apparently 
be the treatment. At the time when puberty should develop, 
and in amenorrhea after young girls have menstruated several 
times, extracts of corpus luteum may be indicated, although 
generally in such patients there is a sub thyroid secretion, and 
small doses of thyroid are more efficient. If these young girls 
are anemic, and in unhygienic surroundings, and are over-work- 
ing physically and mentally, all such undesirable conditions 
should be treated or prevented; i.e., the mere matter of amenor- 
rhea in such young girls is unimportant; certainly corpus 
luteum is not needed in such a case. In older girls and young 



476 THE PRINCIPLES OP THERAPEUTICS 

women with amenorrhea there is generally associated hypothy- 
roidism, and treatment directed toward that gland is more effi- 
cient than is treatment aimed only at ovarian insufficiency. 
Some patients are most benefited by a combination of thyroid, 
corpus luteum, and pituitary extracts. 

Women who always have their menstruation delayed a few 
days, sometimes a week, and suffer in consequence more or less 
nervous irritability, may have it become normal in time by tak- 
ing thyroid or corpus luteum extract, some best with one gland 
treatment and some best with the other, and some with a com- 
bination of both. The physician must recognize that whenever 
a thyroid or corpus luteum extract is given a patient, the treat- 
ment is potent, and may cause harm, and neither should be 
given for more than short periods without supervision. 

In conditions of overweight with amenorrhea, or with increas- 
ing weight at the menopause, the whole glandular symptom 
complex should be studied, and the organ extracts that are indi- 
cated given. Corpus luteum for a time may be advisable, 
especially if the blood-pressure is high, which it often is at the 
time of the menopause. 

Sometimes the blood-pressure is excessively high without 
evident arteriosclerosis and without kidney insufficiency, and 
for such patients corpus luteum is often a very efficient treat- 
ment. It should be recognized that long continued and large 
doses will cause serious loss of blood-pressure, palpitation, 
nausea, vomiting, and depression, and when given for high 
blood-pressure a fall of 15 or 20 mm. should cause the treatment 
to be stopped for a time, and if the systolic blood-pressure is 
below 120 mm. and the extract is indicated, it should not be 
given longer than to lower the pressure 5 mm., and when the 
systolic pressure is lower than no mm. it should not be used at 
all. Sometimes the pressure falls suddenly much lower and 
causes faintness. Corpus luteum will often prevent some of the 
toxic conditions of the menopause. 

If pelvic pain occurs from delayed menstruation, or there 
are uterine pains with insufficient flow and then clot formation, 
corpus luteum extract many times causes such a flow to be- 
come normal. Before resort is had to glandular extracts, how- 



CORPUS LUTEUM 477 

ever, the pelvic condition must be studied from the physical 
standpoint, lest disturbances that could be corrected surgically 
be omitted. 

The relation of the corpus luteum of pregnancy to the vomit- 
ing of pregnancy has already been discussed. Although the 
administration of this gland extract to prevent the nausea does 
not seem logical, practically, there is a great deal of testimony 
to show that it is of value, and it should probably be tried, and 
best in the form of aseptic preparations, which may be obtained 
in ampules, for intramuscular injections. This method of 
administration is also probably the best for high blood-pressure. 

The majority of clinicians use corpus luteum extract in pref- 
erence to ovarian extract because it has tangible activities 
which ovarian extract does not have, but though ovarian extract 
activity is more intangible, many times it is as positive. In 
dysmenorrhea large doses of corpus luteum are sometimes given, 
even from i to 2 Gm. (15 to 30 grains) a day, by the mouth. If 
the drug was to be given for more than a few days such dosage 
would be too large. It should not be given when the blood- 
pressure is very low. 

In delayed menstruation and in amenorrhea the administra- 
tion of extracts of this gland is probably more successful when 
a corpus luteum is present in an ovary but not sufficiently 
functioning. It has not been shown that when the ovaries are 
degenerated corpus luteum can of itself cause menstruation. 
When there is great psychic disturbance just before men- 
struation, it may be tried, perhaps best by intramuscular 
injections. 

Administration. — Corpus luteum extract is best prepared 
from the glands of the sow, and probably for clinical purposes 
the mixed preparations from both pregnant and non-pregnant 
animals are satisfactory. Even if the preparations were made 
from glands of pregnant animals only, they would be more 
active and hence the dose would be smaller; the difference is 
probably only in the dosage. The substance can be obtained 
in powder, in capsules and in tablets. Five grain tablets are too 
large, and 1 or 2 grain tablets are better. 

In very high blood-pressure at the menopause, and in the 



47§ THE PRINCIPLES OF THERAPEUTICS 

nausea of pregnancy, it is best given intramuscularly, and can be 
obtained for this purpose in ampules, each ampule containing i 
mil, winch represents a soluble extract of 0.20 Gm. of the dried 
substance. In a mild case of nausea and vomiting the contents 
of one ampule every other day may be injected; or in severe 
cases, every day. 

The most frequent signs of intolerance to this gland treatment 
are indigestion and headache. The ampules of course have 
better keeping properties than the dried powder or tablets, 
and deterioration may be a cause of these unpleasant symptoms 
from its administration. 

OVARIES 

Function. — At just what embryonic age the ovaries begin to 
furnish their specific hormones has not been determined, but 
the growth of the external anatomical sexual characteristics of 
the female are not entirely due to the secretion from these 
glands. If for any reason the ovaries are removed in the 
young female child, the pelvis does not grow to the usual female 
size, the breasts do not normally develop, more or less hair 
appears on the face, the voice is low pitched, the legs are longer, 
and the mentality may be sluggish, i.e., a castrated female 
takes on the male type, much as the castrated male takes on the 
female type. 

It has long been noted that the earlier the girl menstruates 
the shorter, ordinarily, will be her legs, and the later before 
she develops this function, the longer the legs. Although there 
may be exceptions to this rule, ordinarily the girl ceases to 
grow tall at puberty. Sexual precocity in girls may be due to 
early and more rapid development of the function of the 
ovaries, or may be due to an insufficiency of the pineal gland, 
this gland being supposed to control the gradual sexual develop- 
ment. An increased secretion from the anterior lobe of the 
pituitary may cause an increased and rapid skeletal growth, 
and an under-secretion of the posterior lobe of the pituitary 
may cause the girl to become large, fat, and to develop more 
rapidly external sexual characteristics, but later with such 
pituitary dysfunction the sexual activities may remain infantile. 



ovaries 479 

In disturbance of the pituitary as occurs in acromegaly in 
females there is generally amenorrhea, and with this ovarian 
disturbance there is likely to be some development of the 
masculine type. In subthyroid conditions, although the 
uterus and ovaries may be apparently normal, menstruation 
may not occur, and in real thyroid insufficiency the patient 
becomes obese and the skin is dry, while in pituitary disturb- 
ances the skin is moist and soft. 

The close relationship of the thyroid to the sexual life of 
the female, namely, to the ovarian and to the corpus luteum 
secretions and to menstruation and pregnancy should be 
constantly borne in mind. The thyroid normally hypersecretes 
at each menstrual epoch and during pregnancy, and if it does 
not perform this increased function, the menstruation is not 
normal and may not occur, and the period of pregnancy may 
have serious metabolic or toxic disturbances. The effect of 
ovarian and corpus luteum secretion on the breasts is positive, 
and ovarian removal has even favorably affected inoperable 
cancer of the breast. 

The relation of the thymus gland to the sexual growth of the 
female has been denied, but if the thymus is large and hyper- 
secreting puberty is likely to be precocious and the growth of 
the girl diminished. Anything that stimulates the ovaries to 
increased secretion causes an early development of the girl and, 
after puberty, increases sexual desire. An increase of sexual 
desire also often occurs at the menopause, due to ovarian 
irritability. On the other hand, a too rapid cessation of 
ovarian activity at the time of the menopause may cause 
physical debility, mental depression, and even melancholia. 

Ovarian function is studied by ascertaining the activity 
of extracts of the whole gland including the corpora lutea, of 
extracts of the corpora lutea alone, and of extracts of the 
mature ovaries with the corpora lutea carefully removed, so- 
called ovarian residue. It must logically be admitted that the 
ovaries have an important function before puberty, i.e., before 
the corpus luteum appears. Also it is not rational to consider 
that as soon as the activities of the corpora lutea appear the 
remaining part of the ovaries, the ovarian residue, has no func- 



480 THE PRINCIPLES OF THERAPEUTICS 

tion whatever, though the corpora lutea have been shown to 
have very positive functions. 

X-ray radiations directed toward the pelvis may inhibit more 
or less the activities of the ovaries and the corpora lutea, and 
may, for a time at least, prevent menstruation. 

Menstruation. — The American girl matures, or first men- 
struates, on the average, at about the fourteenth year, but she 
may menstruate as early as twelve years of age, and rarely 
several years later than fourteen. Earlier menstruation is at 
the present time becoming more frequent because this age is one 
of excitement and nerve tension even for girls. Anything that 
increases the thyroid secretion in young girls may hasten pu- 
berty, and thyroid secretion is increased by anything that causes 
sexual excitement. Profuse menstruation in young girls is 
often due to hyperthyroidism, while amenorrhea may be due to 
a subsecretion of the pituitary or of the thyroid, and the con- 
dition of chlorosis often requires thyroid medication. Ill 
health delays puberty. 

It may seem to be a function of the corpus luteum gland to pro- 
mote menstruation, but it has not been determined what decides 
the day and hour of the flow. On the average, about six ounces 
of blood is lost. Although it has been thought that with the 
menstrual blood considerable amounts of calcium, phosphorus, 
and other salts were lost, still it has been more recently shown 
that, though the amounts lost vary at different times, as a rule 
the need for calcium and phosphorus by women who menstruate 
is not greater than the need of men or of women who do not 
menstruate. 

Menstrual blood does not normally clot; if uterine clots occur, 
the bleeding is abnormal perhaps because the thyroid does not 
normally secrete. Profuse bleeding, or too frequent menstrua- 
tion certainly weakens the individual, but more loss of blood 
can be sustained without causing symptoms through men- 
struation than by hemorrhage from any other part of the body. 
Too frequent, or too profuse, or too prolonged menstruation can 
but deplete the blood, as evidenced by anemia and by the loss of 
some element that is concerned in the health of the bones, 
teeth and hair. If this valuable element that is lost is not cal- 



OVARIES 481 

cium, it must be pretty close to it. Also many times pregnan- 
cies cause the mother to lose her teeth and her hair, and too 
frequent pregnancies may cause sufficient loss of calcium (used 
for the growth of her children) to cause osteomalacia. Also 
if a nursing mother begins to menstruate the milk is soon an 
insufficient food for her child. 

Uterine pains in dysmenorrhea may be caused by an excessive 
corpus luteum or a disturbed ovarian activity, and it has been 
suggested that the influence of the developing placenta in 
pregnancy may prevent menstruation, and it has also been 
suggested that the absence of menstruation during lactation 
may be due to some mammary hormone preventing ovulation. 
Directly after menstruation is the time the woman is likely 
to become pregnant. 

Women castrated during menstrual life generally rapidly add 
weight, not only because of the sudden loss of the menstrual 
flow, but also because of the loss of ovarian secretion. There 
is coincident with this loss of ovarian activity more or less thy- 
roid subsecretion and perhaps pituitary subsecretion, as the 
pituitary also takes part in the regular periodic menstrual cycle 
of the woman. If the thyroid should hypersecrete after either 
artificial or normal menopause, weight will not be added, and 
there is likely to be loss of weight, and the vasomotor irregulari- 
ties which are typical of the menopause. 

At the normal menopause which occurs on the average at 
about forty-eight years of age, if the thyroid begins to diminish 
its secretion coincidently and synchronously with the ovarian 
decreased activity and with the cessation of corpus luteum 
activity, very few symptoms occur. If, however, the thyroid 
does not cease its activity but rather continues its cyclical hy- 
persecretion, more or less hot flashes, restlessness, irritability, 
sweatings, and many other associated disturbances occur, more 
aggravated every four weeks. Associated with this disturbed 
nervous condition is likely to be hysteria and many other neurotic 
symptoms. If, on the other hand, the thyroid too rapidly sub- 
secretes at the time of the cessation of menstruation, the woman 
rapidly adds weight, has digestive disturbances, is depressed, 
may be melancholic, and may have symptoms of mild myx- 

31 



482 THE PRINCIPLES OF THERAPEUTICS 

edema. The most frequent age for myxedema is from forty to 
fifty, and at least 80 per cent, of all cases, if not 90 per cent., 
occurs in women. 

Profuse menstruation in young girls may be stopped by feed- 
ing pituitary extracts, and by feeding mammary gland extracts. 
Profuse uterine hemorrhage may occur without fibroids or 
other serious local disturbance, and be caused by pathologic 
ovaries, especially by cystic ovaries. Also quite possibly 
hypertrophy of the mucous membrane of the uterus may be 
caused by hypersecretion of the ovaries. Submucous fibroids 
however, are a frequent cause of venous bleeding, and menor- 
rhagia is frequent just before the menopause, at which time the 
cause must be carefully sought lest malignancy be overlooked. 

W. J. Mayo 1 says "hysterectomy is seldom necessary for 
benign myoma in a woman under thirty-five, and demands an 
excellent reason in a woman under thirty. At forty-five hys- 
terectomy is probably the best procedure. Sutton has shown 
that 10 per cent, of women who require hysterectomy for fibroids 
after fifty have coincident malignant disease." 

Disturbances of the ovaries which may not necessarily cause 
profuse menstruation may cause abnormal mental conditions, 
from simple girlish coquettishness and the desire for male com- 
panions to actual sexual perversion, and even to forms of insanity. 
When the history of such a sequence of symptoms has occurred, 
extirpation of at least one, and perhaps one and a hah ovaries 
is certainly justifiable, and may cure the mental condition. 
Sexual intercourse may correct dysmenorrhea and irregular 
menstruation, and cystic ovaries are more frequent in the un- 
married than in the married woman. 

Osteomalacia is probably due to disturbances of several 
endocrine glands, but is largely due to dysfunction or over-func- 
tion of the ovaries, as it is rare after the menopause. It has 
been said to occur in men, but it is rare in males. There is 
always a disturbance of the calcium metabolism, hence probably 
a disturbed function of the parathyroid glands. 

The proper treatment of osteomalacia is as follows: to stop 
lactation; prevent pregnancy; push nutrition, especially give 

1 Journal A. M. A., June 19, 1920, p. 1685. 



OVARIES 483 

milk and increased amounts of lime and phosphates; and, if 
there is not rapid improvement, to give intensive x-ray applica- 
tions to the ovaries, to inhibit their increased secretion, or to 
inhibit the secretion from possible hypersecreting corpora lutea. 
This x-ray treatment of the ovaries will probably stop menstru- 
ation for a time and prevent pregnancy for a while, but unless 
used very intensively, will probably not permanently sterilize 
the patient. If such treatment is unsuccessful, removal of one 
or one and a half ovaries must be considered. 

Uses. — Just how much of the activities of the ovaries may be 
given a female patient by feeding preparations of the whole 
gland is difficult to determine, but many times feeding of these 
extracts after ovarian extirpation has caused a cessation of the 
disturbing symptoms of the artificial menopause. Frequently 
a better treatment is to combine ovarian substance with a small 
dose of thyroid, if this gland is apparently under secreting. 

Ovarian extract will sometimes wake up a lackadaisical pa- 
tient and greatly benefit the individual, while at other times it 
fails to show any activity. This may be because ovarian ex- 
tracts deteriorate and the active elements in them may become 
disorganized. If there are indications for administering corpus 
luteum, there is no question about the activity of that extract; 
but it cannot be long given, as it is depressant to the circulation. 
It is quite possible, although not yet well demonstrated, that in 
slowly developing girls the administration of ovarian extracts 
is of value. 

If for any reason both ovaries must be removed, the adminis- 
tration of ovarian extracts is logical and may be a help while 
the other endocrine glands are re-arranging their functions to 
meet the new condition; there is no doubt of such an interrela- 
tionship or that the glands endeavor to minimize the disturb- 
ance caused by the loss of one of their number. Whatever the 
disturbance of the individual is, the physician with a knowledge 
of what has happened, plus a study of the symptoms present and a 
thorough knowledge of the function of each gland, can determine 
what is best for him to give in the way of glandular medication. 
The physician, frequently, should prescribe an appropriate com- 
bination of the glands whose functions he thinks are insufficient. 



4S4 THE PRINCIPLES OF THERAPEUTICS 

It is probably very frequent in older girls and in young women 
that there is an insufficiency of the ovarian secretion. Whether 
this deficiency is best met by stimulating the thyroid with 
iodine, by feeding ovarian extract, by small doses of corpus 
luteum, or by giving ovarian residue, must be decided by cli- 
nicians, and by clinical studies. When the right combination or 
the right glandular extract is found and given, the improvement 
in the patient is sometimes phenomenal. Digestive disturb- 
ances, headaches, and dysmenorrhea disappear, and the whole 
mental and physical condition of the patient is improved. 

With the advance of the science of surgery and the ability 
to preserve normal tissues for most any length of time, it will prob- 
ably be found advisable and possible when total extirpation 
of the ovaries must be done, or when both ovaries are seriously 
diseased, or when they have not developed and apparently there 
is an absence of ovarian secretion, that transplantation of 
healthy ovarian tissue will be more frequently and successfully 
accomplished. 

Administration. — Tablets and powder of ovarian extract may 
be obtained, and the dose is from 2 to 5 grains, once or twice a 
day. Large doses are not needed, and many times very small 
doses are of active value, decidedly stimulating patients and 
even causing sleeplessness. 

These ovarian extracts all contain more or less corpus luteum, 
but so little of this glandular tissue that they rarely can cause 
any harm, and they do not lower the circulation as do prepara- 
tions of pure corpora lutea. However, preparations are now 
made of so-called "ovarian residue," which means ovarian tissue 
without the corpora lutea, and theoretically this substance 
should present the activities of the ovarian glands without the 
combination of the activity of the corpora lutea. This prepa- 
ration is an improvement on the ordinary ovarian extract, and 
keeps better. If one wishes the corpora lutea activity, that can 
be obtained; if one wishes the ovarian interstitial tissue activ- 
ity, that can be obtained. Ovarian residue is offered in tablets 
each representing 5 grains. The best ovarian extracts are pre- 
pared from the glands of the pig. 






MAMMARY GLANDS 4^5 



PLACENTA 



There is no good proof that there is an internal secretion 
from the placenta, and there probably are no toxins presented 
by the placenta that cause eclampsia, as has been suggested. 
It has been proved that when placental extracts are given to 
nursing women the secretion of milk is not increased, but that 
the infants fed on such milk grow more rapidly than control 
cases. At the present time there is no recognized use for 
placental extracts, although it may inhibit too frequent 
menstruation. 

MAMMARY GLANDS 

Description. — The mammary glands begin to develop early 
in embryonic life, are present in both boys and girls, and before 
puberty, in most girls, grow as an evidence of their approach 
to maturity. Young boys before puberty may also have some 
swelling and tenderness in their rudimentary glands. In some 
girls these glands do not grow, but remain rudimentary, but 
their size seems to have no special relationship to the establish- 
ment of the menstrual function. Many girls with very largely 
developed mammary glands, especially if they have subsecre- 
tion of the posterior lobe of the pituitary, may have, for long 
periods, entire absence of menstruation. Therefore, although 
normally the mammary glands swell and become tender just 
before the menstrual period in most women and girls, still 
the size of the glands has no relation to the menstrual 
function. The size of the glands does not necessarily indicate 
the amount of glandular secretory tissue, as large mammary 
glands are often mostly fat. 

The mammary glands of virgins and old women may rarely 
contain milk sufficient for nursing. Also milk may be secreted 
by the glands of male children and even of infants. 

Function. — Normally the mammary glands in females 
hypertrophy and often are painful for some days before men- 
struation, and if menstruation is delayed the soreness and tender- 
ness may last for some time. This pain generally ceases as soon 
as menstruation begins. Some hormone from the interstitial 
cells of the ovary or from the corpus luteum stimulates the 



486 THE PRINCIPLES OE THERAPEUTICS 

mammary glands to enter into the normal menstrual cycle, the 
same as the thyroid and the pituitary normally hypertrophy 
at this period. If pregnancy occurs the mammary glands grow 
from some stimulus furnished at first perhaps by the corpus 
luteum of pregnancy, and later probably by some chemical 
stimulus furnished by the placental tissue, so that they reach 
their full size and are ready to function at the time of parturition. 

Just what it is that develops lactation after parturition is 
not known, or whether that function continues by the stimula- 
tion from the sucking child or whether these glands are contin- 
ually stimulated by the ovaries, is a question for future decision. 
Both ovaries, have, however, been removed without interfering 
with lactation. In extra-uterine pregnancy, the mammary 
glands also hypertrophy, and then cease to grow and begin to 
diminish in size after the pregnancy has ceased, and the same 
is true if the child dies in utero. The absence of menstruation 
during lactation is probably due to an inhibitory influence of 
the mammary glands on the ovaries, while too early menstruation 
may be due to hypersecretion of the thyroid or pituitary glands. 

After the menopause the glandular portions of the mammary 
glands more or less atrophy, but in fat women the fat remains. 
After artificial menopause the glandular portion of the mammary 
glands may atrophy, and sometimes cysts in the glands dis- 
appear. On the other hand, after the cessation of menstruation, 
when no more corpora lutea are formed and the activities of the 
ovaries diminish, cancer readily develops in the breasts of 
women. 

Another interesting relation between the breasts and the 
female pelvic organs is that when the newly born child is placed 
at its mother's breast, contractions of the uterus occur. Women 
can generally prolong the amenorrhea period by prolonging the 
lactation, and if for any reason lactation does not occur, or it is 
thought best that the woman should not nurse her child, 
menstruation begins much sooner than when normal lactation 
has taken place. Also the administration of mammary gland 
extracts will generally stop profuse menstruation, especially 
in young girls, and will also many times postpone to normal a 
too frequent menstrual cycle. 



MAMMARY GLANDS 487 

What actually starts the secretion of milk in the parturient 
woman has not been determined, but it has been suggested that 
the placenta just before parturition furnishes a chemical impulse 
to the mammary glands. The administration of placental 
extracts has not increased the milk secretion of women in whom 
that secretion was deficient, but it has been demonstrated that 
women who have normal milk secretion and are fed such extracts 
have their children grow more rapidly than the children of 
women who are not fed placental extracts. It has also been 
suggested that some uterine hormone may be the cause of 
starting the lacteal secretion. The corpus luteum apparently 
does not stimulate this secretion, although it may cause the 
glands to grow. This is logical, because something stimulates 
the glands to grow just before menstruation, but when a new 
corpus luteum develops lactation is not in evidence. 

It has been suggested, but not proved, that extracts from 
the posterior lobe of the pituitary and infundibulum may stimu- 
late lacteal secretion. It has also been noted that the cortical 
substance of the suprarenals is increased in size during lactation. 

To sum up our present belief it would seem that the 
mammary growth is first stimulated by developing ovaries; 
that periodic stimulation perhaps comes from the corpus 
luteum; that the growth during pregnancy probably comes from 
the corpus luteum of pregnancy and from ovarian interstitial 
stimulation ; that lactation is started by some hormone produced 
from the uterus or placenta; and that continuance of lactation 
may be aided by ovarian hormones, but it is probably promoted 
by the local stimulation of the nursing child. 

All of the endocrine glands that are hypertrophied and whose 
secretion is increased during pregnancy for the development of 
the child are probably more or less extra active in their func- 
tions during lactation, as all these secretions are carried in the 
blood during pregnancy to the uterus and after parturition to 
the mammary glands, and during lactation the hormones reach 
the child through the milk. 

If the woman menstruates during lactation, the milk as a 
nutriment is impaired, and the child will not grow, or at least 
will not thrive. In other words, the mother cannot lose 



4SS THE PRINCIPLES OF THERAPEUTICS 

hormones, salts, and nutritive elements from her blood through 
the menstrual flow without depleting the milk of elements of 
nutrition necessary for the child. Although experimenters 
have lately seemed to show that not much calcium is lost in the 
menstrual blood, still it is certain that the mother's milk must 
represent large amounts of calcium and phosphates for the 
growth of the child, and she could not afford to lose these salts 
by menstruation while nursing the child. The mammary 
gland may have the ability of synthetizing various elements 
necessary for the milk to be a perfect food for the child. 

With our present knowledge we have no facts to show that 
the mammary gland has an internal secretion, and both glands 
can be entirely eradicated without causing, apparently, any 
harm to the individual. The only internal function the glands 
seem to have is that they can at times, reflexly, or through a 
hormone, cause contractions of the uterus, and the contrac- 
tion caused by the reflex of the babe to the breast directly after 
parturition is positive and unquestioned. Also, it is quite 
probable that the uterus involutes more rapidly and better 
when the woman suckles her child, possibly from the stimulation 
of the child at the breast, and as clinically demonstrated, the 
administration of mammary extracts will generally, if the cause 
is not pathologic, stop profuse menstruation. 

Uses. — The only use for extracts of the mammary gland is 
in the profuse menstruation of young girls and young women, 
and in menorrhagia occurring at the time of the menopause; 
in other words, in functional bleeding. If there is a local 
organic reason for the increased flow, of course it should be 
treated by proper local methods, but when a young girl floods, 
or menstruates every two or three weeks, and profusely, 
mammary tablets, two or three a day, beginning one week 
before the expected period, will very frequently postpone the 
period to the normal time. It is also advisable to begin on the 
third day of a profuse menstruation and give the girl three or 
four tablets a day, which will often shorten the period. Menor- 
rhagia at the menopause may be stopped in the same manner. 

Administration. — Mammary extracts are prepared from the 
mammary glands of the sheep and cow, and occur either in 



TESTICLES 489 

powder or tablets. Tablets may be obtained which contain 2 
grains of the desiccated mammary gland of the sheep, each 
tablet representing eight grains of the fresh substance. The 
dose is as above described. 

TESTICLES 

Description. — The internal secretion of the testicles is 
probably elaborated by the interstitial cells, and secretions or 
hormones produced by these cells are the cause of the develop- 
ment of the secondary male characteristics. Castration in 
childhood develops a eunuch, a man of the female type. The 
boy after castration grows large; adds fat; hair does not develop 
on the face, and in the axilla and on the pubis it is scanty, 
although there is plenty of hair on the head; the larynx does not 
enlarge, so that the voice is not of the masculine type; the 
prostate gland does not enlarge, and the mammary glands 
may hypertrophy. There are symptoms of subsecretion of 
the posterior lobe of the pituitary and of the thyroid, which 
protfably accounts for the increased deposits of fat and the 
more or less sluggish mentality. At times the thymus gland 
has been found enlarged after castration. x If the testicles are 
removed later in life, the prostate atrophies and fat is deposited, 
and the patient is likely to become obese, i.e., any interference 
with the testicles causes other endocrine glands to become 
disturbed. 

As age advances there is more or less decreased testicular 
activity, much as there is with age decreased ovarian activity, 
except that in the man these gonadal changes occur five to ten 
years later. Just what relation this secretion has to the 
development of gray hair and the imperfect nutrition of the 
teeth must probably be considered coincident with lessened 
function of the suprarenal and thyroid glands. 

Function. — The seminal and procreative part of the testicle is 
entirely separate in its function from the interstitial part. 
The seminal part of the gland is not essential to growth, or 
perhaps to health, although it is necessary for normal virility. 
If the interstitial part of the testicles does not develop or 
properly secrete the boy gives more or less evidence of the 



490 THE PRINCIPLES OF THERAPEUTICS 

eunuch: If these glands are insufficient, there may be all types 
of effeminate boys and men, depending on the amount of 
insufficiency, and when thyroid and testicular insufficiency 
both occur in childhood infantilism results. 

The interstitial epithelial cells are termed the "cells of 
Ley dig," which cells apparently produce the substance that is 
required for normal masculine development. Maturity of the 
male occurs when spermatozoa are developed in the seminal 
part of the gland. At this time hair begins to grow on the 
boy's face, the voice changes, and he begins to assume the 
sturdy growth and type of manhood. During this rapid 
development the interstitial cells are also more active. While 
the development of spermatozoa is indicative of the perfectly 
normal man, absence of spermatozoa is not necessarily shown by 
any outward evidence or by any impairment of the man's health. 

When it has been necessary to remove the testicles, or they 
have been ablated by injury, transplantation of undamaged por- 
tions of the testicles or of testicles from some other individual 
have prevented the disturbances caused by castration. This 
must mean that the secretion produced by the interstitial 
cells of Ley dig is essential to prevent the results of castration. 

The relation of the male gonad hormones to the mental 
development of the individual is doubtless the same as the 
relation of the female gonad hormones to her mental develop- 
ment. Certain it is that normal testicles and normal ovaries 
are essential to the best mentality, and spayed men and animals 
are never quite the same as normal animals. The relation of 
diseased ovaries and testicles to mental abnormalities and 
insanities is interesting, and perhaps often positive, but clinical 
experience has not given sufficient data for a discussion of the 
relationship. 

A discussion of the testicles would not be complete without 
reference to the years of experimental work and surgical 
successes of G. Frank Lydston, who has urged for many years 
that testicles can be successfully transplanted, and, when they 
are diseased and must be enucleated, that healthy portions may 
be transplanted into the abdominal muscles. When enough 
healthy tissue cannot be procured from the testicles operated 






TESTICLES 491 

upon, the most successful transplants are testicles taken from 
young men and boys who have suffered, violent death, and 
procured soon enough not to have suffered degeneration. 
Lydston believes a small piece is sufficient. He advises trans- 
planting into the abdominal muscle, or into the scrotum, and 
does not find that the tissue entirely disappears until after 
twelve or eighteen months. During this time the transplanted 
gland apparently secretes its hormones and gives them to its 
host with the usual stimulation that comes from interstitial 
testicular tissue. VoronofFs transplants of testicular substance 
in sheep and goats seems to have positively demonstrated that 
such transplants furnish potent secretions. The preservation 
of a part of the testicle, if possible, or the transplantation of a 
part of normal human testicle, if both testicles must be removed, 
is as essential for the welfare of a man as is the preservation of 
a part of normal ovaries or the transplantation of a normal 
ovary for the woman. 

Probably it is the secretion of the interstitial cells that 
causes sexual desire and sexual activities, and possibly this 
secretion is also stimulant to the thyroid gland, and through it, 
or directly, is stimulant to the brain. 

The cause of impotency may be due to insufficiency of the 
testicles from disease, ablation, or hyposecretion; also there 
is frequently a psychic cause for impotency. The psychic cause 
may be treated psychopathically or by suggestion. Testicular 
insufficiency may be treated by transplantation of a piece of 
testicle, as impotency does not seem to be benefited by the 
feeding of testicular extract. However, with preparations of 
the interstitial cells, the cells of Leydig, it may be possible 
to postpone premature senile debility in men, especially in 
those who have had some testicular disease. 

It has been presumed that the spermatic fluid was more 
necessary to, or indicative of, the virility of man than the rest 
of the testicle. It now seems that the interstitial portion of 
the testicle is really the more important, and represents the 
hormones necessary for man's mental and physical health. 

Uses. — Testicular extracts are rich in nucleoproteins, and 
therefore tend, like all nucleins, to lower blood-pressure. It 



492 THE PRINCIPLES OF THERAPEUTICS 

has not been shown that the feeding of testicular extracts made 
from the whole glands, or any spermine preparations, given by 
the mouth or injected hypodermatically have prevented senility, 
or caused any improvement in the health of degenerated men, 
whether there is arteriosclerosis or impotency. 

The testicular glands are made more active by anything that 
improves the circulation if the circulation is depressed, and 
even digitalis may become an aphrodisiac, likewise strychnine. 
In subsecretion of the thyroid, thyroid extract is a testicular 
stimulant. 

Symptoms of hypersecretion of the testicles are not recog- 
nized, and symptoms of their abnormal secretion are, perhaps, 
not often enough recognized. It will probably be found justi- 
fiable to castrate all incurable male criminals, for their own 
sakes as well as to prevent offspring. 

Administration. — It should be noted that considerable nuclein 
is given the patient who takes testicular extracts. The proper 
dose of extracts made from the interstitial cells of Leydig is still 
to be determined, but, theoretically, a small dose daily of any 
endocrine gland should be sufficient. The indications for the 
trial of such treatment have been above suggested. Tablets 
may be obtained made from the desiccated testicles of the ram, 
and each two-grain tablet represents about fourteen grains of 
fresh substance. The dose is a tablet two or three times a day. 
Tablets may be obtained made from the interstitial cells (cells 
of Leydig) of the testicle, each tablet representing about eight 
grains of the undried interstitial cellular tissue. The dose may 
be from one to three tablets a day,but the exact dose is subject 
to clinical decision. 

PROSTATE GLAND 

Description. — This gland probably has an internal secretion, 
and it certainly has an important physiologic function. Its 
secretion seems to cause the spermatozoa to become actively 
motile, and it has been stated that a spermatozoon when mo- 
tilized, perhaps by the prostatic secretion, can traverse an inch 
in seven and a half minutes. The prostate probably normally 
grows from stimulation by a hormone of the interstitial cells of 



THYMUS GLAND 493 

the testicle. Over-activity of these cells may be a cause of an 
enlarged prostate; or some pelvic irritation or bladder irritation 
is doubtless a more frequent cause of an enlarged prostate. 
More than one-third of all men over sixty years of age have an 
enlarged prostate, although they may not all have symptoms 
from it. The enlargement may be partly muscular, but it is 
mostly glandular, or adenomatous. Therefore this increased 
glandular part of the gland probably furnishes an increased 
secretion. It is possible that this increased secretion is de- 
pressant or disturbing, and may be one of the causes of sexual 
perversion and mental disturbance ; and rarely fine educated men 
after sixty years of age become peculiar sexual perverts and 
become abnormal mentally, perhaps due to the secretion of an 
hypertrophied prostate. The relation of the prostate to these 
abnormal conditions has not been sufficiently studied. It is 
quite possible that removal of the hypertrophied gland may at 
times be indicated, even if the ordinary symptoms of obstruc- 
tion are not present. Some symptoms which occur later in 
the life of men, at about sixty, and which are not dissimilar to 
"change of life" in women may be due to a disturbed or in- 
creased prostatic secretion. 

It should be noted that not all of the symptoms of prostatic 
trouble are due to hypertrophy, as the gland may atrophy in old 
age and cause insufficiency of the bladder with dribbling urine, 
incontinence, and later residual urine and even retention. 

There is at the present time no logical therapeutic use for 
prostatic extracts, and their administration might cause serious 
mental depression. 

THYMUS GLAND 

Description. — There is considerable doubt as to whether this 
gland should be classed with the endocrine glands of internal 
secretion; still it apparently has activities that should call 
for most careful consideration. It is most active in very 
early childhood, perhaps reaches its full growth when the child 
is two years of age, and generally grows smaller until at puberty, 
when the gonads become most active, it has generally more or 
less atrophied to an unimportant, inactive condition. However, 



494 THE PRINCIPLES OF THERAPEUTICS 

it may remain as a tangible gland until late in life, and this 
normal involuted gland may become hypertrophied and 
apparently active in many conditions and disturbances, 
especially in disturbances of the thyroid, and often in disturb- 
ances of the pituitary gland. If the thymus is still active at 
the age of puberty the secondary sex characteristics are slow in 
development. 

The gland lies in the upper part of the thorax, in the 
mediastinum, the posterior surface extending down upon the 
right auricle. It is in close contact with the larger blood-vessels 
of the upper part of the thorax and with the pneumo- 
gastric and recurrent laryngeal nerves. Consequently, enlarge- 
ment of this gland can cause many symptoms due to pressure or 
distortion of blood-vessels and nerves, and great enlargement 
may cause what is termed thymic death. Careful percussion, 
fluoroscopy, and roentgenograms will outline the size of this 
gland. It consists of two portions, the cortical and the medul- 
lary, and is divided into lobes and follicles of adenoid tissue. 
Its structure is not unlike the tonsils, and therefore not unlike 
lymphoid glands. 

On account of its large content of nucleated cells, the thymus 
gland contains a large amount of nucleoprotein, and con- 
sequently a large amount of organic phosphorus. Although so 
closely interrelated with the thyroid, this gland so frequently 
becoming hypertrophied when the thyroid is abnormal, still it 
does not contain iodine. 

Function. — The thymus gland is not essential to life; it can 
be removed and the animal survive, but many symptoms after 
thymectomy have been attributed to the absence of its activity. 
After thymectomy growth, especially of the skeleton, has seemed 
to be more or less inhibited, the bone growth has been abnormal, 
and the bones have seemed to be more fragile. 

It would seem that the thymus gland must have something to 
do with the calcium and phosphorus metabolism; therefore, 
considerable to do with the rapid growth of bones which occurs 
in the infant and in childhood. What its interrelations are 
with the parathyroid glands in the calcium metabolism, or with 
the anterior pituitary body in bone construction has not been 



THYMUS GLAND 495 

ascertained. No particular pathologic condition has been 
shown to be caused by dysfunction of the thymus. 

Perhaps in nearly half of all cases of Graves' thyroid disease 
the thymus is hyper trophied. Whether this hypertrophy 
is due to the same infection which caused the disturbance of the 
thyroid, or is due to some hormone from the thyroid stimulating 
the thymus to renewed activity, or whether the thymus is 
called into activity by the system to overcome some toxemia 
caused by the hyperthyroidism, is not known. It seems prob- 
able that the thymus becomes active to offset some disturbance 
of the thyroid hyperactivity, and it has been shown that the 
enlarged thymus has not increased the dangers of the hyper- 
thyroidism. Therefore, decreasing the size of the thymus in 
Graves' disease by means of the x-ray is not logical treatment. 
In fact, the administration of thymus extracts has many times 
been of benefit in hyperthyroidism. 

It is not necessary to enumerate the considerable list of 
experimenters who have considered the thymus to furnish an 
active secretion, although the gland has been repeatedly shown 
not to be necessary to life. These experiments have apparently 
shown that extirpation in animals causes the following symp- 
toms; loss of weight; stunted growth; general weakness; bone 
disturbances with a tendency to fragility and to fracture; 
sometimes tremors; some loss of mental ability; loss of hair; 
interference with sexual development; and later death. 

Lately, in a very careful criticism of the older experiments 
and in a series of very careful experimentations on the effects of 
thymectomy, Park and McClure 1 have seemed to show that 
previous experiments could not be relied upon, and in their 
careful resume of the work of others and their own, have come to 
the conclusion that the thymus is not essential to life in the 
dog, and that extirpation of the thymus produces "no detect- 
able alteration in the hair, teeth, contour of the body, muscular 
development, strength, activity, or intelligence of the experi- 
mented animal. " Also, that "extirpation of the thymus 
probably does not influence growth or development," although 
they cannot declare that it may not retard development and 

1 Amer. Journ. Dis. of Child., Nov., 1919, p. 317. 



496 THE PRINCIPLES OF THERAPEUTICS 

may not delay the closure of the epiphyses. They also did not 
find that extirpation of the thymus made any alteration in the 
organs of internal secretion; and it has previously been supposed 
that the spleen, the hypophysis, parathyroids, and adrenals 
were disturbed by thymectomy. Also previous experimentation 
by other investigators has seemed to show that the testicles 
and ovaries showed fatty degeneration after thymectomy. 

In spite of this seemingly conclusive evidence of the unim- 
portance of the thymus gland as an organ of internal secretion, 
we cannot ehminate the fact that this glandular substance is 
apparently very active in early life, gradually atrophies later, 
and normally ceases entirely its activity at the time the thyroid 
commences its full function. Also the thymus is the most active 
during the period of rapid bone growth, and it contains some 
elements necessary to further the production of bone. If this 
gland is insufficient, there may be a lack of lime salts for bones, 
and they may soften, although its insufficiency is not the cause 
of rickets. Insufficiency of this gland may be one of the causes 
of marasmus in infants. 

Howell 1 says that "the thymus prevents the excessive accu- 
mulation of acid in the body,particularly phosphoric acid or its 
compounds." He thinks it also "exerts this action probably by 
synthesizing these acids into nucleinic acid or nuclein com- 
pounds." He also says that the thymus must be connected 
with growth, and must have some relationship to the reproduc- 
tive glands. Sajous thinks this gland has a great deal to do, 
as Howell suggests, with the normal development of the sexual 
glands. He thinks precocious old age, i.e., senile children, may 
occur because of an insufficient thymus. What relationship 
the subsecretion of the thymus may have to early adult senility 
is, of course, a question. 

In the marasmus of young children, with emaciation, various 
skin disturbances, shrivelling of the skin and the general ap- 
pearance of senility, there is probably a lack of vitamines in 
their diet, these infants generally receiving artificial foods. 
However, some of these vitamines may be essential to the 
perfect function of the thymus. 

1 Textbook of Physiology, 1913, p. 855. 



THYMUS GLAND 497 

Sajous thinks that the backwardness of children and idiocy 
may be due to insufficient thymus secretion, either congenital or 
from injury of this gland from some infection ; and in Mongolian 
idiocy an insufficient thymus may play its part in causing this 
condition. He thinks the lymphocytes that develop in the thy- 
mus carry important soluble nucleins to the tissues and to the 
brain, stimulating its growth. This gland is not like other lym- 
phoid glands, but is an epithelial organ, and the lymphocytes of 
the thymus are very much larger than those of lymph glands. 

Pathology. — This gland may be alone hypertrophied or may 
enlarge in association with other lymph glands. The chief 
symptom of an enlarged thymus is obstruction to respiration in 
certain positions of the child's head, or there may be venous con- 
gestion of the head due to pressure on the large blood-vessels. 
There may be several attacks of spasm of the glottis and diffi- 
culty of breathing before a final fatal attack occurs. Whether 
the cause of thymic death is due to suffocation, or whether it 
causes pressure on the vagi nerves, on the vessels, or on the 
right auricle and the death is a heart death, has not been deter- 
mined. 

The thymic gland child is generally pretty well nourished, in 
contra-distinction to the tuberculous child. This fact may aid 
in the diagnosis when it is difficult to tell whether the enlarged 
mediastinal glands are due to tuberculosis or whether there is an 
enlarged thymus, the dullness at times being about the same, 
A radiograph of the chest will aid in the diagnosis. 

Any infection, especially of the mouth, throat and tonsils, that 
can disturb the thyroid can also disturb the thymus, especially 
during childhood. Also, such chronic diseases as tuberculosis 
and syphilis may cause disturbance of the thymus. Probably 
more than one-third (and some statistics show one-half) of all 
cases of Graves' disease have an enlarged thymus. 

Like every other enlargement of a secreting gland, it may be 

an hypertrophy which furnishes more secretion, or it may be an 

enlargement which does not furnish more secretion, in fact it 

may be enlarged and still undersecrete. Consequently, the 

mere fact of an enlargement dose not necessarily prove the gland 

is hypersecreting. In the so-called status thymolymphaticus, 
32 



498 THE PRINCIPLES OF THERAPEUTICS 

with an enlarged thymus as well as enlarged lymph glands and 
hypertrophy of all adenoid tissue, there may not be an increased 
thymus secretion. Probably when the thymus secretion is in- 
creased, the blood-pressure is lowered, as injections of nuclein 
lower blood-pressure. 

The lymphatic state is not necessarily fatal; in fact, children 
grow with large amounts of adenoid tissue, a large thymus, and 
increased lymphoid tissues generally; however, these children 
are not good subjects to fight infection of any kind. Their with- 
stand power is diminished ; their circulatory ability is generally 
poor; they may be of normal weight and even fat, but their 
tissues are flabby; they are generally pale; their mental condi- 
tion is likely to be " lymphatic " as it is termed, sluggish, though 
they may be good natured and of a quiet, easy-going tempera- 
ment. Such a patient is not a good surgical risk, and even re- 
moval of adenoids and tonsils may cause considerable anxiety. 
Sudden heart failure may occur during anesthesia, and thymic 
death may occur in young children. Some of the unexpected 
deaths during anesthesia are thymic deaths. 

It is possible that some of the so-called anaphylactic reactions 
or increased susceptibility of certain individuals to drugs, or to 
food or vegetable poisons, may be due to an irritability of the 
thymus. Some cases of asthma are due not only to pressure 
from an enlarged thymus, but may be due to a persistent thy- 
mus that enlarges on anaphylactic provocation. 

The interrelation of thymus and parathyroid, or pituitary, 
or other glandular disturbances in such conditions as epilepsy, 
dementia praecox, and other forms of mental disturbance is not 
known, but it may play some considerable part in the cause. 

That the thymus has something to do with the development of 
the sexual glands seems probable, and associated with this dis- 
turbed secretion of the thymus there is perhaps disturbed 
suprarenal activity, which may be the important part in the 
disturbances or imperfect development of the testicles and 
ovaries; in fact, lymphatic patients generally have small, 
imperfectly developed genitalia. 

The lymphatic diathesis is not necessarily confined to young 
children, and adults may suffer from it, as evidenced by weak- 



THYMUS GLAND 499 

ness and lack of general tone caused by left-over adenoid tissue, 
hypertrophied tonsils, and palpable cervical and inguinal 
glands. In a man the signs of the lymphatic state are a small 
thorax; round full hips and thighs; small genitals; soft skin; and 
scanty hair on the face, axillae and pubis, and, in the latter 
location, of the feminine transverse formation. A woman 
afflicted with this lymphoid hypertrophy may have scanty hair 
on the body, but may have hair on her face. Some of these 
structural conditions are doubtless due to coincident dysfunc- 
tion of other endocrine glands. 

The treatment of a dangerously enlarged thymus is best by 
the roentgen ray, used intensively. If the danger of suffoca- 
tion is great, a tracheotomy could be done, or a tube could be 
passed through the mouth well down the trachea. However, the 
results from the x-ray treatment are rapid, and after a few 
treatments the gland is generally found to be smaller. One or 
more treatments should be again given in a few months. 

It is a question whether, or not, the thymus should be treated 
by the x-ray and be thus reduced in size in Graves ■ disease. 
As previously stated, it has not been determined that the thy- 
mus (unless it is excessively enlarged and causing harm from 
pressure) is causing adverse symptoms in Graves' disease. 
However, it is'possible that some of the sudden deaths in thyroid 
operations have been thymic deaths, but collapse of the trachea 
from softened rings due to thyroid pressure has been the cause 
of some such sudden deaths. 

Surgical removal of the thymus, or a large part of it, is a 
serious operation at any time, and should perhaps rarely be 
done, as roentgen ray treatment has proved so satisfactory. 

A child with a dangerous enlargement of the thymus should 
remain in a hospital under careful observation, so that trache- 
otomy and intubation can be immediately done if suffocation is 
imminent during the period when the roentgen ray therapy is 
being pushed. This presupposes that a thymic death is from 
suffocation, which it may not be. Improvement from the x-ray 
may be noted in forty-eight hours, and sometimes sooner. 

It should be emphasized that enlargement of the thymus is 
not a rare condition, and it may be one of the important factors 



500 THE PRINCIPLES OF THERAPEUTICS 

in the terrible asthma attacks that some patients endure. 
Every asthma patient who does not show some logical cause for 
his condition, as polyps in the nose, or food poisoning as devel- 
oped by protein tests, or poisoning by pollen of the hay fever 
type should have a sinograph taken of the chest and the con- 
dition of the thymus thoroughly investigated. 

Uses.— It has not been shown that the administration of 
thymus is of value in the development of young children, although 
when associated with the administration of calcium prepara- 
tions and phosphates, it may be of some value. There would 
seem to be no question that the thymus has something to do 
with bone formation, but whether its oral administration is of 
any advantage in insufficient bone growth is still a question for 
future decision. 

It has been suggested that it may be of advantage in certain 
mental conditions, but success with such treatment has not 
been proved. Rickets is undoubtedly partially at least due to a 
vitamine deficiency which may be furnished by cod liver oil, 
or perhaps by butter, but the addition of thymus gland extracts 
to the treatment of the child can do no harm. 

Although thymus extracts injected hypodermatically lower 
blood-pressure, given by the mouth it does not seem to cause 
any disturbance of the circulation. The administration of 
these extracts is often of value in some of the disturbances of 
Graves ' disease, some patients being repeatedly made better by 
thymus treatment when they have recurrences of the thyroid 
disturbance. Thymus feeding is probably inadvisable when 
there is uric acid disturbance, or in leucocytosis in any form. 

The dose of thymus is uncertain. Tablets may be obtained 
made from the thymus of the calf, each tablet representing five 
grains of the fresh substance of the gland. 

PINEAL GLAND 

Description. — The pineal gland, sometimes called the epiphy- 
sis cerebri, is a small cone-shaped, reddish body which varies in 
size and rests upon the corpora quadrigemina at the posterior 
part of the third ventricle. It is composed of two parts, a 
cortical and an inner layer; the cortical substance is somewhat 



PINEAL GLAND 501 

like the structure of the anterior lobe of the pituitary, while 
the central part contains more nervous elements. Although 
originally it may have been a sense organ, it is now purely 
glandular in its activities. 

Function. — This gland seems to be associated with other 
glands that are essential to the growth and development of the 
child to puberty. It has its greatest activity during the first 
few years of the infant's life, and then gradually ceases its 
activity toward puberty, although it probably normally never 
entirely degenerates. It apparently has control over sexual 
and mental development, and especially seems to inhibit too 
rapid sexual development in young children. If the pineal 
gland is removed from young animals, they more rapidly 
develop sexually and have an early puberty. 

This gland does not seem to be necessary to life, but McCord 
and others have found that its removal apparently increases 
mental and sexual development when the operation is per- 
formed early in the animal's life. Horrax also found that the 
testicles of guinea-pigs better and more rapidly developed, and 
the females bred earlier after pinealectomy. The symptoms 
from its removal in the adult animal are unimportant. 

Enlargements or growths of this small gland rapidly cause 
pressure symptoms and circulatory disturbances, as the gland 
is in direct contact with the large veins in the center of the 
brain; also pressure in this region may cause hydrocephalus. 
In the adult, tumor growths of the pineal gland can apparently 
cause only headache and the symptoms of a cerebral tumor in 
this location. Uncomplicated enlargement of the pineal 
gland is rare. 

Extracts of the pineal gland when injected intravenously 
cause a lowered blood-pressure, perhaps some heart disturb- 
ance, and possibly a glycosuria. A lowered blood-pressure 
is caused by injections of any extract of nervous tissue. 
Therefore there are no characteristic symptoms from such 
injections. 

( If there is tumor growth or other disturbance causing an 
insufficiency of this gland in early childhood, there is an in- 
creased rapidity of sexual development; the external genitals 



502 THE PRINCIPLES OF THERAPEUTICS 

are increased in size and hair grows on the pubis. The child 
also rapidly develops mentally and physically, and becomes 
precocious. 

Extracts from the pineal body are best prepared from young 
bullocks, as adult pineal glands have not been found to have 
the activity that the glands of young animals possess. 

It was at first thought that feeding this gland to young 
children of slow development would increase their growth and 
their mental activity, and would cause an early maturity of the 
sexual glands. This theory was in direct opposition to the 
belief that privation of the secretion of this gland caused just 
this condition.. This paradox has lately been found not to be 
true. In other words, it is not proved that feeding this gland- 
ular tissue to defective children causes any improvement in 
their condition, although McCord found that feeding pineal 
extracts from young animals to young animals stimulated the 
growth of the latter to normal (not to giant size) and stimulated 
their mental and sexual development. 

A number of cases are on record, some of which have been 
proved to have a pineal tumor and others which are supposed to 
have insufficient secretion from this gland, which have shown 
very early development of all the secondary sex characteristics. 
This gland, supposed at some ancient time to be a sense organ 
for sight, is said by McCord 1 to " contain an active principle 
capable of inducing pigment changes independent of and wholly 
apart from environmental conditions. " 

When this gland degenerates it seems to deposit so-called 
"brain sand," and roentgenograms of adult skulls may show 
shadows from the calcification of this gland. 

Children who mature early and at the same time develop an 
abnormal amount of fat, may have a hyposecretion of the 
posterior pituitary or a disturbance of the pineal gland. It is 
frequently impossible in abnormal children to decide how many 
and which endocrine glands are dysfunctioning. 

At the present time it would seem that the thymus and the 
pineal glands have considerable to do with the normal develop- 
ment of the child, especially its sexual development. Disturb- 
1 Journ. of Exp. Zoology, May, 191 7, p. 207. 



PINEAL GLAND 503 

ance of the thyroid, the adrenals, and of the pituitary can cause 
the child's development to be abnormal. After puberty it 
would seem that the pituitary, thyroid, adrenals, ovaries and 
corpus luteum in the female, and the testicles and perhaps the 
prostate in the male, govern normal health and sexual life. 
Even if it is denied that the thymus and the pineal glands have 
internal secretions, still it cannot be denied that they have some 
important function during early childhood. 

Besides the early precociousness in sexual development 
thought to be due to hyposecretion of the pineal gland, it has 
been suggested that a hypersecretion or an increased secretion 
of this gland during the age of, normal puberty would postpone 
maturity and continue and perhaps perpetuate for a time 
infantile sexual organs. i Infantilism, the lack of mental and 
body growth, may be due to many causes, and is characterized 
by many types, but in most cases there is a slow development, 
or lack of development, of the secondary sexual character- 
istics. In the female normal pelvic and mammary gland 
growth does not occur, pubic hair is absent, and the menstrual 
function is in abeyance. In the male, the genitals remain small, 
hair does not grow on the face or pubis, and the voice remains 
that of a child. 

Herter, in 1908, thought there was a type of infantilism due 
to intestinal disturbance. It is quite probable that some of 
these conditions are due to privation of some type of vitamines 
necessary for complete health and growth of the body and 
for the production of the hormones of one or more endocrine 
glands. It is possible that disturbance or absence of the 
secretion of the pineal may be one of the many causes of cachexia 
in young children. Timme 1 suggests that pineal gland disturb- 
ance may be a cause of progressive muscular dystrophy. 

As yet pineal gland treatment of children who are defective 
mentally and who do not grow or develop is purely experimental. 
However, to children who are delinquent, and do not show 
distinct indications of other glandular insufficiency, small doses 
of pineal extract may be given. Tablets of pineal extract may 
be obtained for such administration which represent J-^o of a 

1 Archives of Internal Medicine, Jan., 191 7, p. 79. 



504 THE PRINCIPLES OF THERAPEUTICS 

grain. Theoretically such a dose need not be given more than 

once or twice a day. 

PANCREAS 

Function. — The pancreas is a gland furnishing two secretions, 
one, the pancreatic juice, which passes by ducts into the 
duodenum, digests both proteins and starches; the other secre- 
tion, furnished by the islands of Langerhans, reaches the blood 
by absorption, and it is this secretion that is closely associated 
with the glycogenic function. When the pancreas is extirpated, 
or there is disease of these islands of Langerhans, the sugar of 
the blood is increased and glucose appears in the urine. While 
many organs of the body are associated in the glycogenic 
function, namely, the pancreas, liver, muscles, suprarenals, 
and the posterior pituitary, disturbances of other glands may 
so upset the glycogenic metabolism as to cause glycosuria; 
but if the islands of Langerhans are diseased, diabetes mellitus 
occurs. Focal infection is probably a frequent cause of disease 
of this part of the pancreas, and therefore of glycosuria and, 
later, of diabetes mellitus. 

If the pancreas is removed, the animal dies. If the liver 
is in trouble, the pancreas may hypertrophy and attempt to do 
extra work, especially the islands of Langerhans. On the other 
hand, if the pancreas is in trouble, the liver seems to produce 
more sugar, the sugar of the blood is increased, and glycosuria 
occurs. In other words, the internal secretion of the islands 
of Langerhans, or the hormones from this glandular tissue, seems 
to control the production of sugar by the liver, and perhaps 
the ability of the muscles and tissues to use sugar. The 
reverse seems to be true of the adrenal secretion. If there is 
too much adrenal hormone in the blood, it seems to stimulate the 
production of sugar, perhaps by activating the posterior lobe of 
the pituitary. The hormones furnished by the islands of 
Langerhans seem to cause normal oxidation of the glycogen in 
the muscles. 

As stated, entire removal of the pancreas causes diabetes and 
is rapidly fatal, and partial removal of the pancreas will cause a 
mild diabetes. In mild forms of diabetes in the human being 
removal of carbohydrates from the food prevents glycosuria, 



PANCREAS 505 

while in severe types privation of carbohydrates does not 
prevent glycosuria, glucose being formed from proteins. Inves- 
tigations have seemed to show that in from % to % of the cases 
of diabetes mellitus lesions of the islands of Langerhans have 
been found. This does not show that the disturbance is always 
primarily in the pancreas. 

While excessive eating of carbohydrates may be a predispos- 
ing cause of diabetes, excessive eating of proteins may also be 
a cause, i.e., if the pancreas is overworked and irritated, dis- 
turbance of the islands of Langerhans may occur. Also the 
internal secretion of the pancreas seems to be closely related 
nervously, or by secretion, to the brain, and any disturbance 
that causes a hypersecretion of the posterior pituitary and 
infundibulum will cause glycosuria. Cerebral injuries and 
disturbances may cause glycosuria, probably because the 
posterior lobe of the hypophysis is stimulated. Suprarenal 
disturbances cause glycosuria, perhaps by the effect on the 
pancreas. 

It has been shown that the blood from the pancreatic vein of a 
healthy animal will not prevent or stop the glycosuria of experi- 
mental diabetes. Therefore it is not the secretion of the islands 
of Langerhans that is in the blood that prevents diabetes. 
Also, feeding of pancreatic substance and pancreatic extracts 
does not cure or seem to in any way affect the progress of 
diabetes. 

It may be briefly mentioned that it is the liver that converts 
carbohydrates into glycogen, which it stores until it is needed 
for muscle use. When it is needed, it is reconverted into glu- 
cose, and is carried to the muscles and tissues, and what is not 
used for immediate energy is stored in the muscles as glycogen 
again. 

Inflammations of the pancreas may occur without causing 
glycosuria, provided that the islands of Langerhans are more or 
less intact. There are various tests to determine the efficiency 
of the pancreas as evidenced by glucose appearing in the urine, 
but such tests should only be considered as a test for carbo- 
hydrate tolerance, and any insufficiency shown may not show 
islands of Langerhans insufficiency. On the other hand, there 



506 THE PRINCIPLES OF THERAPEUTICS 

is a great tolerance to carbohydrates in subsecretion of the 
posterior lobe of the pituitary. 

An ordinary simple test of the carbohydrate function is made 
by giving ioo grams of glucose, in solution, shortly after a 
light breakfast; or it may be given with the breakfast coffee. 
The urine should be examined in three, six, and nine hours, and 
if sugar is found, there is a lowered tolerance for carbohydrates. 

At the present time there is no satisfactory method of admin- 
istering the hormones of the islands of Langerhans, and all 
preparations of pancreas and pancreatic tissue that have been 
offered have proved unsatisfactory in the treatment of diabetes. 
At the present time there is no use for pancreas or pancreatic 
preparations except as a digestant. When pancreas is given 
to patients as sweetbreads it should be recognized that large 
amounts of nucleins are offered the patient, which may be 

inadvisable. 

SECRETIN 

The importance of the hydrochloric acid of the gastric juice 
not only as an aid to stomach digestion but as a germicide must 
be recognized. Another important activity is its ability or 
its function, when it passes into the intestine, to cause the excre- 
tion into the intestine (formed from a substance contained in 
the epithelial cells termed prosecretin) of an important sub- 
stance named secretin. Secretin increases the flow of bile and 
of the pancreatic secretion, but it is soon destroyed in the intes- 
tine by the enzymes of digestion. 

Secretin has also been proved to be an active stimulant to 
peristalsis, and this has suggested its use in constipation, but 
it probably is of no value when given by the mouth, and it 
should not be given hypodermatically or intravenously. When 
injected subcutaneously it increases the number of both red and 
white corpuscles in the blood by stimulating the bone marrow. 
The normal activity of this substance may be the cause of diges- 
tive leucocytosis. 

Secretin may be obtained from the mucous membrane of the 
duodenum and jejunum of a fasting mammal by mascerating 
this mucous membrane with a weak hydrochloric acid solution, 
but its therapeutic use is purely experimental. 



LIVER 507 

SPLEEN 

Function. — The spleen does not produce a vital secretion. 
This organ can be removed both from animals and man and 
death not occur. It easily becomes swollen, congested, or 
hypertrophied in certain diseases, typically in diseases of the 
blood. It may be that all of the diseases in which it is enlarged 
are due to infection, and the hypertrophy and increased activity 
is due to the need for greater purification of the blood and for 
the production of more phagocytic leucocytes. The function 
of the spleen seems to be to produce leucocytes and lympho- 
cytes, and to destroy or at least retain broken-down erythro- 
cytes and leucocytes; hence it improves the blood. It has also, 
associated with the liver and bone marrow, something to do 
with the production of hemoglobin. As the spleen has rhythmic 
contractions and dilations it may aid the portal circulation. 
Under certain conditions of the bone marrow the spleen may 
produce red corpuscles as it is supposed to do in embryonic life. 
In type the spleen is a lymph gland. 

The advisability of splenectomy should always be considered 
in serious destruction of red corpuscles, in hemolytic jaundice, 
and it should, sometimes, be considered in pernicious anemia 
and in spleno-medullary leukemia. It is obvious that if a 
certain amount of splenic tissue is required to destroy normally 
a certain number of red cells a day that twice that amount of 
normal splenic tissue would destroy twice as many red cells a 
day. 

Splenic extracts have been suggested in many conditions, 
but there is no good scientific or therapeutic excuse for adminis- 
tering preparations of the spleen. A so-called hormone has 
been prepared from spleen which has peristaltic activities, but 
for such activity it must be administered hypodermatically, and 
it may produce very undesirable effects, hence such use at the 
present time is not justifiable. 

LIVER 

Extracts of the liver, when given experimentally, lower 
the blood-pressure, and preparations containing the bile salts 
always lower blood-pressure and may increase the activity of the 



508 THE PRINCIPLES OF THERAPEUTICS 

bowels, but they are more or less depressant, and neither bile 
nor bile salts should be long administered. Theoretically, 
when for any reason the bile is absent from the intestines, pre- 
parations of bile might be of advantage, but if the diet is 
properly arranged (namely, foods are given that do not require 
bile for their digestion, i.e., eliminating fats) other laxatives 
are safer than to long administer bile. Also the bile salts 
should not be long given for any possible action they may have 
in stimulating the liver or in preventing deposits in the gall- 
bladder. 

When liver is given as a food it should be recognized that it 
contains a large amount of nuclein, and therefore will increase 
the production of uric acid. 

KIDNEYS 

There is still a difference of opinion as to whether there is, 
or is not, an internal secretion of the kidneys. It is a clinical 
fact that if the kidneys are healthy, entire absence of the excre- 
tion of urine may go on for several days, even four or five, with- 
out uremia occurring. On the other hand, if the kidneys are 
diseased, as soon as the urine is diminished in amount, and 
certainly when the excretion ceases, uremia is immediately in 
evidence. 

Not to discuss here just what causes uremic convulsions, 

whether they are due to irritations of the brain from ammonium 

salts or to acidosis, clinically, many times, the administration of 

fresh, raw kidneys, or of watery extracts made from raw 

kidneys, has prevented for a time uremic convulsions. On the 

other hand, dried preparations of kidneys, or extracts made and 

dried of the glandular tissue of the kidney, have not been of 

great clinical value, except that at times they increase the 

nitrogen output. 

PAROTID GLANDS 

It is doubtful if these salivary glands furnish an internal 
secretion, except that it is exceedingly interesting that when they 
are inflamed in mumps, metastasis readily occurs to the testicles 
in the male, and to the ovaries in the female. Why there is this 
peculiar relationship has not been satisfactorily explained. 



BRAIN 509 

When the parotid gland is disturbed, it furnishes a very toxic 
secretion, and even in mumps it may cause a very high tem- 
perature and a very slow pulse, and the patient may die of 
sudden heart failure. When the parotid gland or glands be- 
come inflamed in serious infections, as typhoid fever, the prog- 
nosis is bad. Therefore these glands are something more than 
pure salivary glands. 

On account of the relation of these glands to the gonads, 
extracts from the parotids have been used in certain forms of 
dysmenorrhea, and in certain conditions of ovarian disturbances, 
and it has been stated that menorrhagia has been stopped by 
such treatment. However, at the present time, there seems to 
be no good therapeutic excuse for using this glandular substance. 
Parotid extracts may be obtained prepared from the parotid 
glands of the ox, each 2 -grain tablet representing 10 grains of 

the fresh gland. 

BRAIN 

Brain extracts have been repeatedly used experimentally, 
in various cerebral intoxications and in epilepsy, as well as 
in different kinds of insanities and in neurasthenic conditions, 
and extracts have also been administered hypodermatically. 
There seems to be no clinical excuse for such medication. 

Brain extracts, however, have been found to be of value in 
promoting coagulation of the blood; therefore in hemorrhagic 
conditions, as hemophilia, preparations of brain substance have 
been both applied locally and injected. This substance con- 
tains a fibrin ferment which will cause coagulation. Even if 
there is plenty of calcium in the blood, the blood will not coagu- 
late unless a prothrombin in the blood will cause the production 
of thrombin. The best physiology now seems to consider that 
the blood does not coagulate in the vessels on account of its 
prothrombin being in combination with an antithrombin. 
When there is a rupture of a blood-vessel and blood flows into 
other tissues or externally, the prothrombin is liberated and 
combines with the calcium salts, thrombin is formed and 
coagulation is the result. 

In bleeders it is the object to present thromboplastic sub- 
stance which seems to be similar to a lipoid of the brain. Con- 



510 THE PRINCIPLES OF THERAPEUTICS 

sequently, preparations from the brain termed brain lipoid and 

kephalin are offered for such use. Other preparations of brain 

extracts are offered under various names as thromboplastins. 

Some of these preparations are made from brain and spinal cord 

substances. A preparation termed Coagulin is prepared from 

blood platelets. The method of using these various sterilized 

substances is described on each package. Externally, the dry 

powder may be applied, or aseptic solutions may be made and 

injected. 

NUCLEIN 

This substance does not properly belong to the Part devoted 
to Organotherapy, as it is generally prepared from substances 
that do not belong to the body. 

Nuclein given by the mouth or hypodermatically may cause a 
leucocytosis. Though once thought to be a stimulant to the 
phagocytes in infection, it has not been proved to be of value 
as an agent for that effect. However, preparations containing 
large amounts of nuclein have been lauded in all acute infec- 
tions, given internally and hypodermatically, and used locally 
on ulcers and injured tissues that do not readily heal. So 
many preparations offer nuclein to the patient, as foods rich in 
nuclein, testicular extracts, thymus gland, and yeast, that pre- 
parations of pure nuclein seem unnecessary. They lower the 
blood-pressure, somewhat increase the uric acid output, and do 
not have the therapeutic value that yeast has, in fact, much of 
the nuclein offered is probably produced from yeast. 

Yeast, both brewers ' and compressed yeast, is more or less of 
a gastrointestinal antiseptic, increases the movements of the 
bowels, cleans a coated tongue, stimulates the production of 
white corpuscles, and often seems to aid in combating various 
streptococcic and staphylococcic infections. Hence, it is a 
valuable treatment for septicemia, and for boils and carbuncles. 

Locally, yeast solutions have been used as vaginal douches, 
and as washes for ulcers and external infected areas. 

Dried brewers' yeast, as well as fresh yeast, contains a 
vitamine that is a stimulant to nutrition, and it also may 
stimulate the appetite. 

The dose of the dried yeast is i to 2 Gm. three times a day, 



MEAT EXTRACTS 511 

with meals. The dose of the ordinary compressed yeast cake is 
% to K, dissolved in water, taken once or twice a day. It 
should be noted that when yeast is given a patient he receives 
nuclein besides its other elements. 

LYMPH GLANDS 

Lymph glands more actively functionate, apparently, in child- 
hood, and more easily become involved in trouble or become in- 
fected during^childhood than during adult life. They not only 
harbor and produce lymphocytes, but they act as fortresses of 
protection against the invasion and the diffusion of pathogenic 
germs. For this reason it has been suggested that lymph gland 
extracts be used in certain forms of infection, and especially 
in lung disease. There seems to be no good excuse for such 
treatment. 

The protective function of these glands should prevent 
their unnecessary surgical eradication. 

BONE MARROW 

The bone marrow produces both white and red blood-cells, 
and it is in serious trouble in pernicious anemia and in myeloge- 
nous leukemia. It seems probable that in both these diseases 
infection from some focus is the cause of the disease of the 
bone marrow. 

Bone marrow, and especially "red bone marrow," i.e., the 
marrow of the long bones of young animals, has been prepared 
in glycerin extracts and recommended for all forms of anemia. 
These extracts seem of special value in pernicious anemia, in 
leukemia, in rickets, and in other nutritional disturbances, 
in stimulating the production of red corpuscles. Whether the 
treatment is any more efficient than iron, or, at times, arsenic, 
or than meat extracts, has not been shown, but the administra- 
tion of these preparations is certainly justifiable, and may prove 
of advantage. 

MEAT EXTRACTS 

The administration of raw, chopped beef, or serum expressed 
from raw beef, or the blood freshly drawn from slaughtered beef, 
have all had their periods of recommendation for the treatment 



512 THE PRINCIPLES OF THERAPEUTICS 

of various forms of impaired nutrition, and especially of tubercu- 
losis. It has been thought, and seems to have been shown, 
that more improvement in heart strength and in the red blood 
count is caused by these raw beef preparations than is produced 
when the meat is cooked. Also, in cardiac weakness in serious 
illness, as in pneumonia and typhoid fever, the serum pre- 
pared by covering a pound of chopped round steak with cold 
water, allowing it to stand for two or three hours, and then 
expressing, with a meat squeezer, all of the juices from the 
beef, and administering this juice (which should be slightly 
salted and kept on ice) during the twenty-four hours, has been 
of advantage to patients. Whether this is one of the left-over 
fads to be abolished as the egg-albumen fad should now be 
abolished, on account of lack of nutritional efficiency, must be 
determined later. At the present time this muscle juice 
nutrition seems to be valuable. 

The administration of raw beef for a long period of time to 
tuberculous patients has had its strong advocates, but is not now 
considered necessary, and has fallen into disuse, the same as 
hyper-alimentation in tuberculosis is now believed to have 
been a mistake. 

There is always a possible danger in administering these 
uncooked meats and meat juices that they may be contaminated 
with tuberculosis or with tapeworm embryos, although with 
first-class round steak the danger from either of these infections 
is very slight. 

It has lately been shown that one of the causes of shock 
after injury is the absorption of muscle extracts from the 
crushed tissues, and it has also been shown that injection of 
crushed tissue extracts is toxic and can cause shock. Probably 
when raw meat extracts are taken into the stomach no such 
undesirable action can occur; however, it suggests the impor- 
tance of not depending entirely upon meat extracts and raw 
eggs to promote nutrition during illness, and that carbohydrates 
and fruit juices are needed. 



PART V 

PRACTICAL THERAPEUTIC MEASURES 

INHALATION 

The value of breathing exercises, without restricting clothing, 
in fresh, clean (dustless) air is not sufficiently recognized. 
Such exercises, taken for some minutes once or twice a day, 
promote health, and, when under medical supervision, are 
of benefit in asthma, in cardiac weakness, and in anemia. 
Breathing exercises are necessary to develop the lungs of 
children and youth especially when the expansion is poor and 
the thorax small. Whether the added benefit of sea air, moun- 
tain air (altitude), dry air, or balsam (pine woods) air is 
advisable is for decision by the patient's physician, but these 
climatic advantages should be utilized in proper cases. 

The inhalation of ether, chloroform, or nitrous oxide gas 
for anesthesia need only be mentioned to show the profound 
impression made on the system by the character or content of 
the inhaled air or gas. Oxygen inhalations for the dyspnea of 
pneumonia and tuberculosis were much in vogue, but its value 
was over-estimated, and harm was sometimes done by such 
inhalations, especially in phthisis. Since the open air treatment 
of these diseases has been found to be essential, oxygen gas has 
been less used and less needed. It has been used, however, 
with advantage in great dyspnea, or apnea, whether the cause 
be pneumonia, tuberculosis, cardiac failure, sudden stoppage of 
respiration during anesthesia, carbon monoxide poisoning, or 
oxygen starvation from sewer, well and cellar gas poisoning. 
In the latter acute conditions artificial respiration or the use 
of a pulmotor may be of greater value, but, if an oxygen tank 
is at hand, the heart may be stimulated by inhalations of the 
gas in conjunction with the forced breathing. In sudden emer- 
gencies inhalation of oxygen may be almost curative, and in 
chronic dyspnea it may relieve the discomfort but it cannot 
33 513 



514 THE PRINCIPLES OF THERAPEUTICS 

cure. The gas should be passed through warm water before 
it is inhaled from a tube passed into a nostril, so that it may be 
moistened and not be dry and irritate the mucous membranes. 
Its administration should be intermittent, each inhalation 
period lasting a few minutes. 

Various medicaments may be inhaled either by vaporizing 
them in a room or in an improvised tent; or a drug may be 
administered more directly by impregnating a respirator 
apparatus with it. This method of treatment is used more 
especially in children who have laryngeal diphtheria or croup, 
and also for all forms of asthma. The air of a room may be 
filled with the vapor of cresols for whooping cough. These 
phenols thus inhaled are said to be germicidal, and it is possible 
that they may kill the germ of pertussis, which is one that is 
readily killed. All creosote or cresol inhaling treatments, 
whether for whooping cough or for laryngeal tuberculosis or 
for some other condition, may cause kidney irritation by the 
absorption of phenol. Many times the most benefit from such 
inhalations is due to the steam or moisture with which the room 
or the inhaled air is impregnated, especially if there is dryness 
of, or membrane in, the larynx. 

In bronchitis, in acute nose and throat colds, in chronic 
catarrh of the nose and throat, in tuberculosis, in all forms of 
laryngitis, and in edema of the glottis, inhaling mixtures may 
be used. They are best administered by means of steam 
• vaporizers or kettles. An emergency apparatus may be readily 
constructed as follows: A cornucopia is made from any stiff 
wrapping paper, the small end is clipped off and the large end 
is placed over a bowl of boiling water to which has been 
added the medicament to be inhaled. The cornucopia and 
bowl are wrapped with a towel, and then the small end of the 
cornucopia is placed in the mouth and the medicated vapor 
inhaled. To improvise a more continuous steam apparatus, 
a small pan containing water and the medicament may be 
placed over an alcohol lamp, and then proceed as above. The 
vapor from various drugs and preparations may be thus^ inhaled, 
but the most useful are the aromatic substances, such as the 
benzoins, pines, and turpentine. The tincture of benzoin is 



INHALATION 515 

especially beneficial, or it may be used as a base and other 
medicaments added to the solution. 

The cornucopia for inhalation must be long enough so that 
the steam carrying the medicament is not received into the 
larynx too hot. Also, the preparation used must not be so 
strong as to irritate, therefore when turpentine, creosote, 
eucalyptol, menthol, or spirit of chloroform are thus given the 
dose must be small. 

The tincture of benzoin may be used for inhalation every 
three or four hours, a teaspoonful in a steam atomizer or in 
boiling water, or a prescription may be written as : 

Mils 
]$ Oil of dwarf pine needles (01. pini pumilionis) 15. 

Tincture of benzoin, q.s ad 100. 

M. 

S. A teaspoonful to be inhaled as directed. 
Shake well. 
Or, Mils 

]$ Oil of pine needles 15. 

Eucalyptol 5. 

Tincture of benzoin, q.s ad 100. 

M. 

S. A teaspoonful to be inhaled as directed. 
Shake well. 
Or, Mils 

1$ Oil of pine needles 15. 

Spirit of chloroform 15. 

Tincture of benzoin, q.s ad 100. 

M. 

S. A teaspoonful to be inhaled as directed. 

Shake well. 

For Ozena 

Mils 
fy Tincture of iodine 2. 

Spirit of camphor 15. 

Eucalyptol 5. 

Tincture of benzoin, q.s ad 100. 

M. 

S. A teaspoonful to be inhaled as directed. 

Shake well. 

Mils 
"Bf, Creosote 2. 

Tincture of benzoin 100. 

M. 

S. A teaspoonful to be inhaled as directed. 



tji6 THE PRINCIPLES OF THERAPEUTICS 

For Whooping Cough 

Mils 

1^ Cresol i 5- 

Oil of pine needles 15- 

Tincture of benzoin, q.s ad ioo. 

M. 

S. A half teaspoonful to be inhaled as directed. 

Shake well. 

For Laryngitis 

1^ Oleoresin of cubebs 5- 

Glycerin 25. 

M. 

S. Place a drop on a cube of sugar and dissolve in the mouth. 

After any steam inhalation the patient should not go out into 
the open air for a number of hours. 

If more continuous inhalation is desired, various simple appa- 
ratus, made of fine wire mesh covering a cotton or absorbent 
pad for the medicament, may be obtained and fastened over 
the nose and mouth. These inhalers will probably prevent 
contagion. A gauze mask may prevent an individual infected 
with influenza or other germs from spraying the atmosphere and 
therefore spreading contagion. Whether these gauze masks will 
prevent the inhalation through this open filter of the minute 
germs of disease is another question. 

Asthma has long been treated by inhalations with the object 
of administering medicaments that relax spasm of the bronchial 
tubes, by a sedative action on the peripheral nerves in the 
upper air passages or by allaying irritation and inflammation 
of the larynx, trachea, and upper bronchial tubes. Most of 
the papers, pastiles or powders that are burned and inhaled 
for asthma contain potassium nitrate (giving some nitrite 
action) and stramonium, more frequently than any other atro- 
pine carrying drug. The beneficial action from the stramonium 
is due to its atropine, and atropine dulls the peripheral nerves, 
while nitrites relax spasm. Cocaine and morphine have been 
added to such inhalations, but such medication is rarely justi- 
fiable. If these drugs are given, the physician must under- 
stand that he is likely to cause the necessity for more such doses 
and perhaps cause the formation of a habit. 



ATOMIZATION 517 

ATOMIZATION 

The upper air passages are more frequently and directly 
treated by atomizers or by spray apparatus. In the physician's 
office such treatments are given by electric (or other) pumps 
forcing the medicated liquid through fine spray points. At 
home various simple atomizers may be used to advantage under 
certain conditions. When using pumped or compressed air the 
spray must not be sent at too great pressure, especially into the 
nasal passages, else injury to the mucous membranes may be 
done. The greatest advantage of atomizing, when gargling or 
swashing are not advisable, is to wash away with some mild 
alkaline solution (best warmed) the mucopurulent and purulent 
secretions of the nose, nasopharynx, mouth, tonsils, and throat. 
Also the spray from the atomizer may be directed to the part 
that needs such treatment. Most any of the mild alkaline 
mixtures that are in vogue may be used for cleansing and sooth- 
ing purposes. The liquid preparations should generally be 
diluted with two or three parts of warm water. The so-called 
"Alkaline Antiseptic Tablet" should be dissolved in about 50 
mils of warm water. The main advantage of an alkaline soothing 
wash or spray is obtained from about the following combina- 
tion, however such a mixture containing them may be camou- 
flaged : 

Gm. or mil 

]$ Sodium chloride i . 

Sodium borate i . 

Water 100. 

To this may be added wintergreen or peppermint flavor, and 
small amounts of eucalyptol or thymol, if desired. After 
cleansing the parts with an alkaline spray or wash, if a medica- 
ment is advisable it may be then applied, as a weak suprarenal 
solution for local contraction of blood-vessels; some mild silver 
solution as 5 per cent, argyrol (stronger solutions are better 
applied by a swab); a tannic acid solution; an iron solution; or 
an iodine solution. 

If the condition to be treated is an infection, as follicular 
tonsillitis, after washing off the surface mucus and pus, hydro- 
gen dioxide solution, diluted with an equal part of warm water, 



518 THE PRINCIPLES OF THERAPEUTICS 

may be sprayed on the part, to be quickly followed by some 
alkaline wash; or a boric acid solution may be used. 

Applications of tincture of iodine (full strength or diluted) 
to some particular part of the throat or mouth, where its ger- 
micidal action is required, are often made. Other valuable 
applications are boroglycerin, Lugol's solution (Liquor lodi 
Compositus), various silver solutions, and sometimes iron solu- 
tions, depending on the particular object to be attained. 

Various oils, applied by means of an atomizer, are especially 
valuable for the mucous membranes of the nose when the nose 
has been douched or sprayed, before the patient leaves the office 
to go into the outside air. Most oil sprays have a very pure 
mineral oil as a base, and contain one or more of the following 
medicaments: menthol, thymol, camphor, oil of santal, pine 
oil, eucalyptol, oleoresin of cubebs, and some aromatic. If 
they are used too frequently on the mucous membranes of the 
nose, throat and larynx, they do harm by drying the membrane ; 
a normal amount of mucous secretion is a protection. 

Whether oil protection is used or not, after spraying the nos- 
trils, if the patient is going directly into the outside air, a pledget 
of cotton or medicated lamb's wool should be placed in the 
nostrils, to remain for an hour or more. 

Simple pocket inhaling tubes containing menthol, camphor, 
oil of eucalyptol, thymol, and pine oil medicaments can be ob- 
tained. They are supposed to aid in aborting colds, and it is 
quite possible that sometimes they do. Pungent ointments are 
often applied to the nostrils for colds. The following combina- 
tion is a suggestion for such a purpose : 

Gm. 

1^ Menthol 0.15 

Camphor o. 15 

Eucalyptol 0.15 

White vaseline 15 . 

M. 

Put into a collapsible tube. 

INSUFFLATION 

Insufflations of powders by means of a powder-blower is 
another method of local treatment of the nose and throat. 



NASAL DOUCHING 519 

The most used powders for this purpose are boric acid, bismuth 
subgalate, and diluted tannic acid powder. The most valuable 
is boric acid, as it tends to promote the secretion of mucus 
from the membrane and aids in removing other exudates, 
and also leaves the surface of the membrane moist and 
not dry, which always promotes the health of mucous 
membranes. 

Before leaving this subject let it be emphasized that both the 
layman and the physician often use too active and irritant 
gargles and sprays on the membranes of the mouth, nose and 
throat. It should be the aim to gently cleanse and carefully 
treat infected areas and to promote the normal secretions of 
these membranes, and not to destroy sensitive and tender tissues 
or to impair their normal resistant and recuperative power. 

NASAL DOUCHING 

Nasal spraying has already been described. Nasal douching 
is valuable for certain conditions, but may be harmful in any 
condition if not properly done, and, like nasal spraying, it may 
also be done too frequently. Its greatest value is in ozena. 
Nasal washing is much recommended as a preventive of "colds," 
by cleansing the nostrils of dust, irritants, and germs as soon as 
the indvidual returns to his home, and before going to bed if 
some other member of the household has a coryza, a sore throat, 
or is coughing. 

Nasal douching or washing is advisable, when properly done, 
in antrum disease. The danger from improper nasal douching is 
that fluid containing substances that cause irritation and in- 
fected mucus may be forced not only into healthy antrums but 
into the eustachian tubes, and later cause inflammation of the 
middle ear. Therefore, the pressure must never be sufficient in 
the nasal passages or in the nasopharynx to force the fluids in 
these directions. Toward this end, the nostrils should not be 
completely plugged with the nozzle of the douching apparatus, 
or at least there should be free exit somewhere for the fluid 
injected. 

A safe method for cleansing the nostrils is to snuff up 



$20 THE PRINCIPLES OF THERAPEUTICS 

fluid placed in the hand, or in a receptacle. The very fact of 
snuffing causes the fluid to pass back into the pharynx where it 
can be expelled through the mouth. It cannot by this means 
enter the eustachian tubes. Many nasal douches on the market 
are dangerous because they plug the nostril, and the pressure in 
the nasopharynx becomes abnormally great. When nasal 
douches are given by a siphon, the fluid flowing from an 
elevated receptacle, the elevation of the reservoir must not be 
higher than the patient's head else the pressure will be too 
great. 

For cleansing purposes the mildest alkaline solutions are 
used. Half a teaspoonful of bicarbonate of sodium and an equal 
amount of sodium chloride to a pint of warm water makes a 
cleansing, non-irritant, soothing douche. If an antiseptic is 
required, boric acid or sodium borate may be used in a warm, 
one per cent, solution. Other stronger antiseptics or deodorants 
may be advisable in ozena. 

In douching for nasal and nasopharyngeal cleansing the 
liquid should enter the nostril that is the most stopped, in order 
for the fluid to have a freer outlet than inlet. This greatly 
diminishes the danger of forcing liquid or secretion up the 
eustachian tubes. After douching the head should be held 
forward and downward, allowing the fluid to drain out; also 
both nostrils should be blown at the same time. 

GARGLING 

Though gargling is one of the most effective methods of 
cleansing the tonsils and pharynx, but few individuals know how 
to gargle. The patient should first take a deep inspiration, then 
taking a suitable amount of liquid into the mouth (not more 
than would represent two swallows for the individual) he should 
make an abortive attempt to swallow, with the mouth held open. 
He cannot swallow into the esophagus with the mouth open. 
He then immediately begins to expel air through the fluid, and 
this bubbling will agitate the fluid enough to properly wash 
off the pharynx and tonsils. To clean the nasopharynx, at the 
end of the gargling process he should throw his head quickly 



GARGLING 52 1 

forward and downward; the fluid will thus reach this cavity. 
Or, as described in nasal douching, the liquid may be snuffed 
through the nostrils and thus reach the nasopharynx, but the 
canal is not as well cleaned as with the former method. The 
gargling should be continued until about half a glass of the 
solution has been used; one mouthful is not sufficient for 
cleansing purposes. 

In acute conditions, where gargling must be frequent, as 
in tonsillitis or diphtheria, the vibrating process may so tire 
the throat muscles and palate that gargling (or gurgling) need 
not be repeatedly done. The patient may swash the liquid 
around the pharynx, tipping the head first to one side and then 
to the other, so as to reach all parts of the tonsils and around the 
tonsils. This is a very efficient means of cleansing the tonsils, 
and is not tiresome. 

There are on the market various cleansing, soothing, alkaline 
compound preparations used for gargling, most of which require 
dilution. The most important ingredients are always boric acid 
or borax, sodium bicarbonate, sodium chloride, and some 
aromatic oils or other flavoring as menthol or wintergreen. 
Some contain thymol, and some eucalyptol, but they are all 
about the same. Various powders are offered, to be dissolved 
in warm water, and these powders contain about the same 
ingredients as the solutions. 

There is no necessity for, and no real advantage in these 
multiple mixtures. One may improvise a good cleansing gargle 
with y± of a teaspoonful of salt and Ji of a teaspoonful of bicar- 
bonate of sodium in half a glass of warm water, with just as 
good results. Or the same amount of sodium borate may 
be used in place of the sodium bicarbonate. 

The advantage of boric acid solutions as gargles cannot be 
over-estimated. A considerable amount of boric acid may be 
placed in the bottom of a bottle, and the bottle kept filled with 
water; then two tablespoonfuls of this saturated solution may 
be placed in a glass with double that amount of warm water and 
a suitable gargling solution is obtained. Individual prescrip- 
tions may be written for each patient, depending upon the 
character of the gargle desired. One is as follows: 



522 THE PRINCIPLES OF THERAPEUTICS 

Gm. or mil 

1^ Potassium chlorate S • 

Boric acid 2 . 

Peppermint water 200. 

M. 

S. Dilute a tablespoonful with an equal part of warm water and use as 
a gargle every three hours. 

Or, 

Gm. 

]$ Potassium chlorate 10. 

Sodium borate 15. 

M. 

S. Dissolve 34 of a teaspoonful in 3^ a glass of warm water and use as 
a gargle as directed. 

Potassium chlorate is very soothing to the mucous membranes 
of the throat and mouth, especially of the latter. 

Any of the suggested gargles may also be used as mouth 
washes. Wintergreen water may be substituted for the pepper- 
mint water, if preferred. If an astringent gargle is desired, 
tannic acid or glycerite of tannin may be added to warm 
water; or a gargle may be prepared as follows: 

Gm. or mil 
1$ Tannic acid 3 . 

Glycerin 15. 

Water, q.s ad 200. 

M. 

S. Use as a gargle undiluted. 

Very soothing gargles are: hot milk and water, equal parts; 
physiologic saline solution; or various mucilaginous decoctions, 
as slippery elm or flaxseed tea, or starch water. 

While boric acid gargles are mildly antiseptic, as well as those 
that contain thymol, the best antiseptic for the mouth is the 
official Liquor Hydrogenii Dioxidi. This solution should be 
diluted with three parts of warm water for a mouth or throat 
wash. It may be used in full strength swabbed onto the tonsils 
or as an application to some part of the mouth, provided that it 
is not used on a suppurating spot that has no free opening, as 
a sinus. Hydrogen dioxide solutions should not be used unless 
there is free outlet for the secretions with which it comes in 
contact, as it forms bubbles which may dissect the tissues. As 



GARGLING 523 

soon as hydrogen dioxide solutions are used, the subsequent 
froth and irritant acid formed should be washed off with some 
alkaline solution. 

While tincture of iron may be applied, in suitable cases, di- 
rectly to a tonsil or other inflamed area, gargles with iron are 
inadvisable. The same is true of silver solutions; they may 
be applied, but should not be used as a mouth wash or gargle. 
Nothing will more rapidly heal canker sores in the mouth than 
one or two applications, at least one or two days apart, of the 
solid nitrate of silver, or of a swab wet with a twenty-five per 
cent, solution of nitrate of silver. 

Phenol solutions as antiseptic gargles are not now much in 
vogue, on account of the danger from swallowing the phenol 
into the stomach, although the solutions when used are very 
weak. The preparation termed "Dobell's solution" is as follows: 

Gm. or mil 

Ifc Phenol , 1. 

Sodium bicarbonate 3. 

Sodium borate 3. 

Glycerin 10. 

Water up to 200. 

M. 

It is quite a habit for patients, when there is irritation 
in the throat, to dissolve potassium chlorate tablets in the 
mouth and swallow the saliva containing this irritant. This 
is not to be recommended, in fact, should be prohibited, as it 
is possible that such irritation might cause ulcer of the stomach. 
Potassium chlorate is harmless if dissolved in water and used 
as a mouth wash, or gargle, even in a saturated solution, which 
is a little more than five per cent. 

Preparations containing hexamethylenamine under various 
names have been recommended and used in the form of tablets 
to dissolve in the mouth, and to be dissolved in water for mouth 
washes and gargles as preventives of colds. While there seems 
to be much clincial evidence that various germ conditions in 
the mouth, nose, throat, and ears have been helped by these 
hexamethylenamine preparations, laboratorily it seems proved 
that there can be no germicidal activity from formaldehyde 



^24 THE PRINCIPLES OF THERAPEUTICS 

preparations except in acid media. When absorbed it acts as 
an antiseptic in the kidney and bladder, where it meets acid, 
but it has not been experimentally proved that it can act on 
any other part of the body as a germicide. 

GAVAGE 

This is a term applied to forced feeding, recourse to which is 
had when for any reason a patient refuses to take nourishment. 
It is generally done by passing a stomach tube, if that is 
practical; if that cannot be done, by passing a long catheter 
through a nostril down into the esophagus. The food intro- 
duced, especially by the latter method, must be very thin and 
contain some concentrated nutriment, warmed to the temper- 
ature of ioi° in the reservoir or receptacle; from a pint to a 
quart may be given at one time. Milk, malted milk, thin 
gruels, and meat juices, sugary and salty solutions, may be' 
thus administered, so that the individual may receive the needed 
nutriments. 

GASTRIC LAVAGE 

Stomach washing in certain conditions is of great benefit; 
it, however, has been done both too frequently and for too long 
a period in the same individual. The simplest method of 
washing out the stomach is to pass the so-called stomach tube, 
which should be not far from five feet in length. In an ordinary 
sized adult individual the distance from the lips to the bottom of 
the stomach is about eighteen inches, and there should be 
marks on the tube to indicate the number of inches passed. A 
good form of this tube is one that terminates in a rubber funnel; 
or if a tube without a funnel is used, a glass funnel may be 
attached to it. The rubber material should be firm and very 
smooth, and should be large enough in size to allow particles of 
undigested food to pass through. Some operators prefer a 
tube with a large opening at the stomach end; others prefer to 
have fenestra? on the sides. 

The tube is passed quickly over the tongue to the back part of 
the pharynx and gently forced into the esophagus, the patient 
being directed to swallow. Some operators prefer to have the 



GASTRIC LAVAGE 525 

tube perfectly dry, believing that the esophageal walls grasp it 
better and pass it more readily on to the stomach. Others 
prefer to wet the tube with hot water so that it will pass a little 
more readily, but the tube should not be oiled. The first 
sensation as the tube is passed is that of nausea, and retching 
soon occurs, but if the operation is repeated in the same 
individual, after two or three times nausea does not occur, 
and the patient learns how to manipulate the tube and aid in its 
passage. 

If the stomach is filled or partially filled, regurgitation occurs 
almost immediately through the tube, and sometimes to prevent 
this kind of regurgitation which is very likely to plug the tube, 
the funnel end of the tube is immediately raised and warm 
water, either plain, or as physiologic saline, or containing a little 
sodium bicarbonate, is poured in and allowed to flow into the 
stomach, until the patient feels a sense of distention, and indi- 
cates it. The funnel end of the tube is then quickly dropped 
toward the basin on the floor before the fluid has entirely passed 
out of the upper end of the tube — in fact the tube should be 
pinched to stop the flow while this lowering operation is done so 
that the fluid from the stomach will flow out into the basin by 
siphonage. This process of filling the stomach and then allow- 
ing the fluid to run out should be repeated until the fluid comes 
away clear. This will often require several quarts of the fluid, 
which should be at a temperature of ioo° or ioi° F. If unpleas- 
ant symptoms occur, or the patient shows unexpected distress 
or signs of heart weakness, the lavage should be abruptly ended, 
If during the outflow the tube becomes plugged, filling the tube 
again with water from above will wash the plug back into the 
stomach, and the siphonage may be again resumed. 

Gastric lavage is done in dilated stomachs, in ptosed stomachs, 
and whenever there is serious obstruction at the pylorus, 
especially if the patient does not vomit and thus evacuate the 
stomach. The improvement in appetite, in nutrition, and in 
good feeling is sometimes very great. Stomach washing is also 
done in cases of poisoning where there has been no erosion from 
a corrosive drug, and is especially valuable in opium and mor- 
phine poisoning. It is also done in serious post-operative 



526 THE PRINCIPLES OF THERAPEUTICS 

vomiting, to wash out the bile regurgitated into the stomach, 
that is causing the nausea and vomiting to persist. A few drops 
of dilute hydrochloric acid in water, however, will sometimes 
cause the stomach to resume normal peristalsis and the pylorus 
to close, and prevent further regurgitation of bile in these post- 
operative cases. However, lavage will prevent fluids remain- 
ing in a paralyzed stomach, and therefore may prevent the 
serious condition of acute dilatation of the stomach, a not in- 
frequent cause of post-operative shock. 

As stated, stomach washing is done too much, and some 
patients acquire a habit for this daily questionable pleasure, 
much as they acquire a habit for large daily rectal enemas, and 
when there is no actual need for this treatment it should be 
discouraged, and prohibited. Washing out the stomach for 
simple hyperacidity is not good treatment. If a patient needs 
an emetic, let him receive it. With a dilated stomach it is 
sometimes difficult to wash out through a tube all the thickened 
debris at the bottom of the stomach. Such patients may lie, 
stomach down, on a bed, with the head hanging over the edge, 
and they will vomit out, with the aid of gravity, the whole con- 
tents of the stomach. Then by taking several glasses of warm 
water, and repeating the process, the stomach will be thoroughly 
emptied and cleaned. 

Contraindications to the use of gastric lavage are serious 
heart lesions; aortic aneurism; cirrhosis of the liver that might 
cause enlarged veins at the lower end of the esophagus; ulcer of 
the stomach; bleeding from the stomach; and poisoning that 
was caused by corrosive irritants. 

ENEMATA 

Injections of water into the rectum to aid the movements of 
the bowels are taken too frequently by many individuals. As a 
temporary treatment, or while a patient is in bed and the ac- 
tivity of the bowels is not normal injections of warm water, or 
of soap and water, or of water containing some more active in- 
gredient, are often advisable, but to continually dilate the rec- 
tum and the sigmoid flexure with large amounts of fluid is a 
serious mistake, as more or less permanent dilatation of the 



ENTEROCLYSIS 527 

lower intestine may be caused. When hardened feces occur, 
however, injections of oil, or of glycerin and water, or of warm 
soapsuds and water, are necessary and valuable. 

Enemas are best given with the fountain syringe, provided 
the pressure is not too great, i.e., that the reservoir is not too high. 
If it is desired to increase intestinal peristalsis on account of gas 
and tympanites, some irritant may be added, such as oil of tur- 
pentine. Sometimes solutions of saline cathartics, as Epsom 
salt, will aid in causing evacuation of the bowels. One of the 
most efficient and the simplest in the way of a small enema is 
half an ounce of glycerin and half an ounce of water injected into 
the rectum by a glass or hard rubber syringe. The movement 
of the bowels will usually occur in from ten to fifteen minutes, 
and the large intestine will generally be well evacuated. This 
is a very simple method of causing evacuation of the large 
intestine when the patient is long in bed, and it is more effective 
than a glycerin suppository. 

ENTEROCLYSIS 

Colon injection is a very useful procedure, and is especially 
valuable when the patient has lost a large amount of fluid, par- 
ticularly if he cannot retain fluids by the stomach, and if the 
more troublesome operations of hypodermoclysis or of saline 
transfusions are not needed. Colon injections are also useful to 
cause absorption of water and perhaps some salts or nutriments 
in conditions in which it is inadvisable to give these substances by 
the stomach, or the stomach does not retain them, or there is 
coma, or the kidneys require more liquid to properly excrete. 

Colon irrigation is of value in all forms of inflammation of 
the large intestine. As a surgical procedure in intussusception 
of the bowel it is sometimes very successful in curing the con- 
dition, but the pressure should not be great, as rupture of the 
bowel may occur, especially if the intussusception has con- 
tinued long enough to cause softening or destruction of the 
walls of the intestine. In impacted feces in the colon, repeated 
and continued injections of warm oil and water are curative. 
In dysenteric conditions the local treatment of the intestinal 
wall is of primary therapeutic importance. 



528 THE PRINCIPLES OF THERAPEUTICS 

Sometimes a double catheter is used for the fluid to enter 
the bowel and immediately return; but if it is intended that 
considerable fluid should be retained, or, if possible, passed 
around to the descending colon by changing the position of 
the patient, the liquid should be passed through a tube that 
may be clamped for a few minutes, and then the liquid is 
allowed to be passed out by the same tube. 

The rectal tube should be soft rubber, but rather rigid, about 
eighteen or twenty inches long, best with fenestras on the 
sides of the tube rather than at the end. The fluid is siphoned 
from the regular reservoir bag placed at an elevation of three or 
four feet. It is often of advantage to have a glass reservoir 
graduated to show the amount of fluid actually used. The 
patient should He on his back, with the hips elevated, either on 
a douche pan, or, better, on a Kelly pad. While it is frequently 
stated that the tube should be passed well into the sigmoid 
flexure, as a matter of fact, it is exceedingly difficult to do this, 
and probably the ordinary rectal tube rarely passes any farther 
than the first part of the sigmoid flexure. Great force should 
not be exercised as the tube simply doubles on itself; the only 
way to aid its upward passage is to start the flow of the liquid, 
and then the tube may be inserted a greater distance. The 
temperature of the fluid should be 102 to 103 F. in the reser- 
voir, as it will lose heat while passing through the tube and the 
fluid entering the intestines should ordinarily be from ioo° to 
ioi°F. 

The amount of fluid injected at one time may be a pint, a 
quart, or more, depending on the discomfort which it causes. 
If it is desired to wash the whole colon, if possible, the quantity 
injected should be as large as the patient will comfortably 
retain. Then the patient should He on the right side, to aid 
the fluid in flowing through the transverse colon to the ascend- 
ing colon. He then should reverse his position to allow aU the 
fluid to flow out. At times it is well to use several quarts of 
solution in repeated injections and outflows at the same sitting. 
At other times it is best for the patient to retain the injection 
until he can go to a toilet, or commode, and evacuate the Hquid 
by ordinary peristaltic action. Or, he may attempt to retain 



URETHRAL INJECTIONS 529 

the fluid for a short time and then evacuate it. If abdominal 
pain is caused by these injections, the amount of fluid that 
has been used is too large, or the medicament used was too 
irritant. 

Tannic acid solutions are sometimes injected; also quinine 
and ipecac solutions, in dysenteric conditions. For cleansing 
purposes physiologic saline solution, from 0.5 to 0.9 per cent., 
or a bicarbonate of sodium solution, or a salt and soda solution 
may be used. If borate of sodium or boric acid solutions are 
used they may be of from 2 to 4 per cent, strength. They wash 
off the mucus and are mildly antiseptic, but large amounts of 
such fluids should not be allowed to remain in the intestine. 
Weak potassium permanganate solutions are sometimes used. 
Silver solutions in small amount are often used, but they are 
generally inadvisable unless the treatment is to be applied only 
a short distance up the intestine. Retained silver nitrate 
solutions are dangerous, as, even if they are neutralized by 
injected sodium chloride solutions, it is uncertain how much 
silver will be absorbed. It is not known how much silver of the 
various organic preparations can be absorbed and cause poison- 
ing. This is not to state that applications made through the 
proctoscope or even some short distance up the intestine are 
not valuable and are not perfectly safe, but the safety of higher 
injections of silver is questionable. 

Injections of oil to soothe irritated membranes and to soften 
fecal matter and to coat the intestines are often useful, olive 
oil being the oil most frequently employed. However, mineral 
oil administered by the stomach will soon reach the colon. 

URETHRAL INJECTIONS 

Almost the only object of anterior urethral injections is to 
promote the cure of gonorrhea, or to prevent venereal disease 
in the male. High injections and urethral washings with a 
high siphon tube, and therefore with force, the so-called Valen- 
tine apparatus, was a mistake, and such injections should not be 
given. By these injections many times the urethra was torn by 
pressure, infection was driven into the tissues, the tissues were 

made soggy, strictures were caused, and the disease was pro- 
34 



530 THE PRINCIPLES OP THERAPEUTICS 

longed. For cleansing purposes and to curtail and shorten the 
disease, if possible, urethral injections must be given frequently, 
sometimes four or five times a day. 

The patient must be instructed how to give himself these in- 
jections. He should first urinate ; then he should clean the parts 
very carefully before the injection is given. The syringe, gener- 
ally a glass one with a soft rubber, cone-shaped nozzle, capable 
of holding about 20 mils of liquid, should be warmed by pre- 
viously filling it with hot water, and then the solution to be 
used is drawn into it. The penis is then held in the left hand, 
the glans between the forefinger and thumb, which support it 
from underneath; the syringe in the right hand is then intro- 
duced into the meatus and the liquid is slowly injected. The 
syringe is then removed and the meatus is pinched with the 
fingers- so as to retain the fluid for as long a time as the patient 
has been instructed, from one to five minutes. The fluid is then 
allowed to run out. 

The liquids employed for the prevention of infection are sil- 
ver solutions (either the nitrate or the organic salts), or a weak 
corrosive sublimate solution. Local curative treatment of 
gonorrhea consists of silver solutions of proper strength, or, at 
times, simple alkaline washes. Later, milk of bismuth solu- 
tions may be used, or more in vogue, zinc sulphate solutions. 

Deep urethral injections can only be well done by the physi- 
cian, and posterior urethral injections require a special syringe 
for the application of the medicating fluid directly to the part 
diseased. Or the urethroscope may be passed, the mucous 
membrane studied, and the diseased areas swabbed with the 
medicament. 

Prevention of Venereal Infection. — The U. S. Public Health 
Service publishes the following rules of procedure: 

To prevent gonorrhea in the male. — "1. Wash the genitals with 
soap and water, followed by a 1-2000 bichloride solution. Dry 
the parts thoroughly. 

"2. Empty the bladder. 

"3. Inject into the urethra a 2 per cent, protargol, or a 10 per 
cent, argyrol solution freshly made. Hold in the urethra five 
minutes. Urinate at the end of this time." 



BLADDER IRRIGATIONS 53 1 

To prevent syphilis in the male. — "Immediately after the 
prophylactic treatment for gonorrhea above described, anoint 
the whole penis, especially the glans, corona and foreskin, and 
also the anterior portion of the scrotum, with ss^i per cent, 
calomel ointment, rubbing in thoroughly, taking at least ten 
minutes for the operation. Cover with oiled silk or wax paper, 
and allow to remain for several hours before washing the parts. 
Since the water content of the base renders the calomel more 
active, it is important that the ointment be made with lanolin 
instead of the fats usually employed for salves. Care should be 
exercised that the lanolin is not anhydrous." 

BLADDER IRRIGATIONS 

The bladder may be irrigated by means of a single catheter 
by injecting fluid to a sufficient amount, and then disconnect- 
ing the catheter from the reservoir and allowing the fluid to 
run out into a pus pan or other receptacle. Or, a two-way 
catheter may be used, one tube for the injection and the other 
tube for evacuation. Or, at times it is best, after filling the 
bladder, to allow the patient to evacuate the liquid after 
the catheter has been removed. The elevation of the reservoir 
should not be over three feet, and the injection should cease as 
soon as the patient complains of distention. When there is in- 
fection and pus in the bladder, great care should be taken not to 
allow sufficient pressure to force liquid up the ureters. Also, 
it is often inadvisable to pass catheters through an inflamed 
urethra, as many irrigation processes have caused secondary 
inflammation of an otherwise healthy bladder. 

The solutions used should be warm, best about ioi° F. in the 
reservoir, and mildly antiseptic and cleansing solutions may be 
used, as boric acid, borate of sodium, physiologic saline, bicarbo- 
nate of sodium, or permanganate of potassium solutions. Some- 
times small injections, with a proper syringe, into the neck of 
the bladder of a weak solution of nitrate of silver, or other 
silver solution, may be advisable; or a larger injection of a very- 
weak silver solution may be used. One must be sure, however, 
that these larger silver solutions are almost immediately 



53? 



THE PRINCIPLES OF THERAPEUTICS 



completely evacuated. If not, they must be washed out, 
perhaps with a neutralizing sodium chloride solution. 

Bladder washings should not be done unless there seems to be 
a positive necessity. Many bladder inflammations can be cured 
by rest, diet, hot sitz baths, free ingestion of water, prostate and 
seminal vesicle massage when it is indicated in the male, relief 
of constipation and of disturbed rectal conditions, correction of 
other coincident pelvic disturbances in the female that may 
cause reflex bladder irritability, and by proper medication. 
Chronic cystitis, however, may require for a time daily bladder 
washings. 

Cystoscopic examinations require the bladder to be filled 
with liquid, and great care must be exercised lest bleeding be 
caused. Injections of fluids into the pelvis of the kidney by 
catheterization of the ureters is very difficult, and should be 
attempted only by a physician or surgeon who has thoroughly 
acquired the technique. 

VAGINAL IRRIGATION 

There is considerable difference of opinion as to the frequency 
with which, in normal women, the vaginal douche should 
be used. It is claimed by some gynecologists that the daily 
vaginal cleansing douche is harmless and advisable. Others 
state that it tends to remove normal secretions and make the 
mucous membrane unhealthy. It is quite possible that the 
middle ground should be taken, that with normal secretions 
and without purulent catarrhal inflammation, and with the 
patient having a daily or every other day sitz bath, the vaginal 
douche is unnecessary, though advisable after menstruation. 

Various apparatus are offered for vaginal douching; the best 
is the fountain syringe and a glass tube with a closed end 
and fenestras on the sides. The tube should be passed well 
up toward the uterus, and then gentle warm irrigation from a 
douche bag may be given. For cleansing purposes the tempera- 
ture may be anything that the patient desires. When there 
are indurations or firm exudates in the pelvis, or if it is desired to 
cause local heat to aid in the absorption or removal of inflamma- 
tory exudates, hot douches may be used, as no° F., or even 



HYPODERMATIC MEDICATION 533 

hotter. It is a question whether such injections are any more 
valuable than the sitz bath would be, or as valuable, in fact. 

The solutions used may be simple physiologic saline, or boric 
acid or borate of sodium solutions of a strength of i to 2 per 
cent. The majority of the advertised powders to be used for 
this purpose are largely and mostly boric acid. 

The best vaginal irrigation occurs when the patient lies on her 
back at the edge of the bed, on a Kelly pad or on some other 
arrangement for the water to flow out into a receptacle. Or 
these douches can be well given in the bath tub. The patient 
should, with her hand, close the orifice of the vagina around the 
tube to allow the fluid to completely fill the vagina. 

Permanganate of potassium solutions, and, at times, stronger 
antiseptic solutions may be used, when ordered and supervised 
by a physician. In various conditions of the cervix or the upper 
vagina antiseptic tampons, made of ichthyol or boroglycerin, 
have their therapeutic use. 

INTRAUTERINE IRRIGATION 

This is not a frequent procedure, except after dilatation of 
the cervix and curettage, but it has been used to stop uterine 
hemorrhage, the water being at a high temperature, as 125 F. 
The solution used is always sterile water or physiologic saline, 
or possibly boric acid solution. The pressure of any uterine 
injection must not be sufhcient to cause liquid or secretions to 
be driven into the Fallopian tubes. In septic uterine condi- 
tions intrauterine irrigation is in complete disrepute, and there 
probably is no excuse for such treatment as long as there is free 
drainage. Irrigations in this condition have increased, rather 
than diminished, infection. 

HYPODERMATIC MEDICATION 

This is a most useful method of administering drugs when 
quick action is desired, but with the multiplication of ampules 
of active drugs and of hypodermic tablets, and with the wave of 
vaccine treatment that is now rising, the tendency is to use the 
hypodermic needle too frequently. 



534 THE PRINCIPLES OF THERAPEUTICS 

An all-glass hypodermic syringe is generally the best; the 
plunger should be removable so that a tablet may be dropped 
into the barrel for solution. The proper method of using a 
hypodermic syringe is as follows: a teaspoonful of clean water 
should be boiled over an alcohol lamp or gas flame; the barrel 
of the syringe should then be filled, or half filled (many tablets 
for hypodermic medication require but one mil of water for their 
solution and it is unnecessary to cause the disturbance of injec- 
ting a greater amount) with the boiled water; the needle end 
of the syringe is then stopped with the finger (the hands being 
clean), the plunger is then removed, and the tablet is dropped 
into the hot liquid; the plunger is then gently re-inserted, the 
barrel inverted, needle end up, and the solution is agitated until 
the tablet is thoroughly dissolved. When the plunger of 
the syringe cannot be removed, the proper method is to fill the 
syringe with the required amount of boiled water from 
the spoon; the spoon is then emptied, and the water from the 
barrel of the syringe is forced out into the spoon, the tablet is 
dissolved in the water in the spoon, and, after solution has 
occurred, the fluid is again sucked into the barrel. In either 
case, the needle, previously sterilized, is now adjusted to the 
syringe, and the syringe is then held, needle upward, and slowly 
the air bubbles are forced out until the first drop of liquid ap- 
pears at the orifice of the needle and the syringe is ready for use. 

The parts of the body usually selected for hypodermic injec- 
tion are the arms and legs, often best the inner surfaces, as the 
more flexible and the softer the skin, the less pain the injection 
will cause. The blood-vessels, especially the surface veins, and 
the nerves must be avoided, and injection should not be made 
where the skin is close to the bone. The skin of the part se- 
lected should be painted with iodine or washed with hot water 
or alcohol. A portion of the skin is then pinched between the 
thumb and forefinger of one hand while the other hand intro- 
duces the needle into the fold of the skin so pinched, generally 
upward toward the body, almost parallel to it but at a slight 
angle, through the skin. The needle must be sharp, clean, and 
perfectly beveled; it is inexcusable to use a needle with a 
shoulder. If a proper needle is rapidly thrust through the 



ASPIRATION 535 

skin, there is practically no sensation. The thumb and ringer 
holding the skin is now relaxed and gently holds a larger portion 
of the tissues to be injected. The piston, or plunger, should 
then be depressed steadily, not too slowly or too rapidly, until 
the whole injection has been given. Too slow injection is 
wearying to the patient; too rapid injection tears the tissues. 
The needle is now quickly withdrawn, and the part injected 
should be gently stroked upwards, which aids in the distribution 
and absorption of the fluid. 

The needle should go well through the skin into the loose 
connective tissue beneath it. All fascia, tendons and muscle 
sheaths must be avoided. Also/as above stated, where the skin 
is bound down tightly to the underlying tissues is not a suitable 
place for a hypodermatic injection. With an aseptic syringe 
and needle and clean methods an abscess should never occur 
from a hypodermic injection. 

Some drugs, or their preparations, for hypodermatic use, 
are but slowly absorbed from subcutaneous tissues, or cause 
pain after they are injected. These should be injected deeply 
into the belly of a muscle, as a deltoid or a biceps; injections 
of mercury are often given into the gluteal muscles. Absorp- 
tion is very rapid of soluble drugs injected intramuscularly, 
next in rapidity to when they are injected intravenously. The 
drugs that are- best given intramuscularly are: ergot, digitalis, 
camphor, arsenic and quinine preparations, strophanthin (when 
not given intravenously), epinephrine and pituitary solutions. 
All drugs should be thus administered when a patient is in a 
condition of shock, and hence has a very sluggish surface 
circulation. 

The endermic method, i.e., the injection of substances between 

the layers of the skin, is used only for local reaction, for vaccine 

and protein tests. 

ASPIRATION 

By this term is meant the removal by suction of fluid of 
any kind from any part of the body. If there is any consider- 
able amount of fluid to be removed, some large vacuum suction 
apparatus should be employed. A small syringe with a longer 
needle than the regular hypodermic needle and with a barrel 



536 THE PRINCIPLES OF THERAPEUTICS 

that will hold 10 mils or more is used for diagnostic purposes, 
first, to determine that fluid is present in doubtful cases, and 
second, to determine the character of the fluid. These diag- 
nostic needles are not used frequently enough in pleural con- 
ditions; physical signs are not always positive in determining 
the presence or absence of fluid in the chest. 

Surgical cleanliness should be used in every detail, whether 
aspirating for diagnostic purposes or for the withdrawal of 
fluid, and the punctured spot should be sealed with collodion. 
The suction of the larger apparatus should not be too strong, 
and if large amounts of fluid are to be aspirated from the chest, 
for instance, it should not be done too rapidly, and if much 
coughing or if dyspnea is caused, the whole of the fluid should 
not be removed and the aspiration should cease. 

It should be recognized that aspiration for pus is not success- 
ful in doing more than relieving the immediate pressure; pus 
must have free exit. On the other hand, it has lately been 
decided that empyema following influenza and pneumonia 
should frequently not be operated upon as soon as pus has been 
diagnosed, as greater dyspnea is caused by the entrance of 
air into the chest and the other lung is interfered with in its 
activity. However, while waiting for a favorable time to 
operate, pressure from the pus may be relieved by aspiration. 

For fluid in the abdomen, the best method of evacuation is 
by means of a trocar. The aspirating needle should not often 
be used in abdominal conditions, and when fluid is removed 
from the abdomen, pressure on the walls should be gently 
exerted by means of a many-tailed bandage, or by other 
means, so that the loss of abdominal pressure may not be 
sufficiently great or so rapid as to cause sudden lowering of 
blood-pressure, anemia of the brain and cardiac failure. 

Ordinarily, in removing effusions from the chest, the best 
regions for puncture are in the eighth or ninth intercostal spaces, 
about two inches below the angle of the scapula, or between the 
seventh and eighth ribs in the post-axillary fine. To avoid the 
intercostal artery, the needle should be inserted close to the 
upper border of a rib. The insertion of the needle should be 
rapid, and suction should immediately take place, so that air 



LEECHING 537 

may not be injected into the cavity. Suction must also be 
taking place when the needle is rapidly removed. 

WET CUPPING 

This method is now rarely used to withdraw blood from the 
body. It is generally much better to use leeches for local 
bleeding, or venesection for general bleeding. When wet 
cupping is done the skin is made surgically clean, and generally 
the better method is to apply a dry cup for a few minutes first, 
then remove the dry cup, and puncture or scarify the skin just 
enough to cause oozing of the blood. The cup is again applied, 
and is retained in position as long as the blood continues to 
flow. Wet cupping should not be done to feeble patients. 

LEECHING 

This is a method of causing depletion by the abstraction of 
blood; generally, however, other methods are better. Although 
leeches occur in American brooks and streams, the imported 
leech is the one that is most efficient, and the Swedish leech is 
perhaps the best, and will draw sometimes as much as twenty 
mils of blood, while the American leech will not draw half that 
amount. 

The best method of applying a leech is to place it in a glass 
tube of proper size, open at both ends, termed a leech glass. 
The leech is thus directed to the exact spot at which it is de- 
sired that it bite. The skin should be cleansed and a little 
sweetened water or milk rubbed on this spot to hasten the leech 
to fasten its teeth into the skin and begin its suction work. 
Leeching should not be done on the face, as slight scars may be 
left. The leech secretes a liquid which prevents coagulation of 
the blood, and for this reason sometimes when the leech is 
removed, bleeding persists, unless pressure is used to stop it. 
Generally several leeches are applied in a small area around 
the part at which local bleeding is desired. If for any reason 
it is advisable to remove the leech, it can be made to let go by 
dropping a little salt on it; it should not be pulled off. 

Leeches are frequently applied back of the ear, in imiamma- 



53S THE PRINCIPLES OF THERAPEUTICS 

tions of the middle ear and mastoid; they are used on the back 
of the neck in meningitis, and may be applied to the temples in 
inflammations of the eye, although, as just stated, they may 
leave scars. They are sometimes used in acute inflammations 
of the throat and they may be applied to the groin for inflamma- 
tion of the testicles. 

VENESECTION 

Blood-letting by phlebotomy has an ancient and harrowing 
history and fell legitimately into disrepute. However, there 
are conditions in which venesection is advisable and even life- 
saving, and it should doubtless be resorted to more frequently 
than it is at the present time. 

Venesection is generally done on one of the veins at the inner 
surface of the elbow, and the method of procedure is as follows : 
the skin is made surgically clean, perhaps best with iodine, and 
a bandage is placed tightly around the upper arm so as to retard 
the venous flow, and not to interfere with the arterial flow (the 
veins generally quickly become prominent, as the conditions for 
which blood-letting should be done are generally the conditions 
in which there is a surplus of blood in the circulation); the 
forearm is then grasped firmly with the left hand, the thumb and 
finger pulling the skin tightly over the swollen vein, either 
the median basilic or the median cephalic being the vein 
selected; the vein is then punctured with a trocar needle, similar 
to the lumbar puncture needle. The amount of blood to be 
withdrawn depends entirely upon the condition, and the pulse 
at the wrist of the other hand shows when the blood-pressure 
has sufficiently dropped. Or, the blood-pressure of the patient 
being known, it may be taken again by an assistant, and when a 
sufficient fall has occurred, it will indicate that the bleeding 
should cease. If the blood should cease to flow, it shows that 
a slight clot has probably occurred, which may be gently wiped 
away with sterile gauze. When enough blood has been with- 
drawn, the bandage is removed from the arm. Sometimes an 
incision is made in the skin and before the vein is punctured 
or incised a stitch is passed through the skin, to be later fast- 
ened after the operation is completed. Needless to say, the 



VENESECTION 539 

whole operatior and the instruments used must be surgically 
clean. 

In infants where the veins are not easily located, even with 
dissection, a perfectly simple and safe procedure is to puncture 
the superior longitudinal sinus. This is best reached by intro- 
ducing a needle with a plunger at the posterior angle of the 
anterior fontanelle. The needle should be graduated, and 
the depth to which it is introduced depends upon the age of the 
child and the thickness of the skin and fascia, usually from % Q 
to % § of an inch. The longitudinal sinus lies directly under and 
is adherent to the overlying tissues, consequently the lessened 
resistance is noted the instant the sinus is entered. Removal 
of the plunger permits the blood to come through the needle. 
This method is also employed in giving intravenous medication 
to infants. 

The usual surgical asepsis must be observed and enough 
assistance must be had to keep the infant's head absolutely 
quiet. Special instruments have been suggested and used for 
carrying out the technique. 

The indications for blood-letting are high pressure sufficient 
to endanger the cerebral arteries; it is doubtful if venesection 
is advisable after an apoplexy has occurred. It has been done 
in plethoric individuals in the first stage of pneumonia when the 
patient was likely to die from congestion in both lungs; also 
sometimes with benefit in a later stage of lobar pneumonia, 
when there is a serious damming back of the blood into the 
right ventricle. There would rarely be any indication for 
venesection in influenzal pneumonia. When there is damming 
back of blood in the lungs and acute dilatation of the heart in 
valvular disease, life may be saved by venesection and coinci- 
dent administration of ergot intramuscularly. Venesection is 
advisable in some forms of sunstroke with high pressure and a 
strongly acting heart. In uremic conditions with high blood- 
pressure and danger of apoplexy or sudden dilatation of the 
heart venesection is indicated, also it may deplete the blood of 
irritants that cause convulsions and coma. In puerperal 
eclampsia, unless there has been profuse and free bleeding from 
the uterus, venesection should be done. 



540 THE PRINCIPLES OF THERAPEUTICS 

INTRAVENOUS INJECTION OF SALINE SOLUTIONS 

These injections are generally given, as in the transfusion of 
blood, into the median basilic or cephalic vein at the elbow. 
The skin is made surgically clean, often best with tincture of 
iodine; the upper arm is constricted by an elastic or other 
bandage sufficiently to stop the flow of blood in the veins; the 
arm is held firmly with one hand and the skin pulled tightly 
over the dilated veins at the bend of the elbow; the proper 
needle for this purpose is then plunged upward slowly through 
the skin into the vein; it should not be plunged too rapidly 
through the tissue as it is likely to slip over the side of the vein 
or pass clear through it. Many times it will be found, because 
the circulation is very poor or the arm is fat, that the vein can- 
not be discovered by the above method, and an incision through 
the skin is necessary to expose it. The vein being found, the 
needle is then inserted as before, and later the incision in the 
skin is stitched. When thus ready for injection the bandage is 
removed from the arm. If any swelling should appear around 
the point of injection, the injection being given slowly, it shows 
that the needle either has not penetrated the vein or has gone 
through it, and that the fluid is being forced into the tissues. 
When the injection is completed, the needle is rapidly with- 
drawn, the site of the puncture pressed for a moment, and the 
part sealed with collodion. 

The solution to be injected should be what has been termed a 
physiologic saline, namely, 0.9 per cent, of sodium chloride in 
warm sterile water. A so-called " normal" saline solution is 
one containing 0.6 per cent, of sodium chloride, and a " deci- 
normal" solution is one that represents }{q of this strength. 
The solution for injection should be accurately and not carelessly 
made, unless there is some great emergency, when a teaspoonful 
of common salt to a pint of boiled water may be used. Too weak 
or too strong sodium chloride solutions damage the blood cor- 
puscles. When possible, fresh sterile distilled water should be 
used rather than boiled water. Generally still better is a solu- 
tion containing the following salts, which makes the content of 
the solution more or less like the salt content of the blood serum, 
namely : 



SALINE SOLUTIONS 541 

Gm. or mil 

Potassium chloride o . 10 

Calcium chloride 0.25 

Sodium chloride . 

Sterile water 1000 . 



Sterile tubes containing these salts in the above proportion and 
in just the amount sufficient to add to a quart of sterile water 
can be obtained. The proper apparatus, needle and clamp for 
these injections, and the technique can be learned in the 
clinical laboratory and in the hospital service. 

Care should be taken that the air is completely expelled from 
the tube and needle before the injection is made. The reservoir 
should be held only about a foot above the arm so that the injec- 
tion will not proceed too rapidly; it should take about thirty 
minutes to inject a quart of fluid. Too much liquid injected, 
if the circulation is weak, may cause edema of the lungs. 

Saline transfusion is now less frequently done than before 
the transfusion of blood became so successful. The indications 
for the use of saline transfusion are: when there is hemorrhage 
and the transfusion of blood is not possible; in serious infection 
to keep the vessels well filled and thus prevent absorption of 
toxins; and when there has been great loss of fluid from the 
body, as in cholera and some cases of infantile diarrhea. In 
diabetic coma sodium bicarbonate solutions should be given 
intravenously after venesection and the withdrawal of a con- 
siderable amount of blood. Also in uremic convulsions the 
patient may be bled and then warm physiologic saline injected, 
unless there is anasarca. To prevent and to combat diabetic 
coma and acidosis an intravenous injection of 500 mils of a 
4 per cent, solution of sodium bicarbonate should be given. 
As in sterilizing this solution some of the bicarbonate becomes 
the more irritant carbonate, before it is injected sterile carbon 
dioxide gas should be passed through the solution to reconvert 
the carbonate into the bicarbonate of sodium. 

The amount of fluid injected may vary, but probably should 
never exceed a quart, and, as above stated, the injection should 
be made very slowly: If there is general edema, or there is 
edema of the lungs, saline transfusions should not be given. 



542 THE PRINCIPLES OF THERAPEUTICS 

Unless the condition is urgent, hypodermoclysis or the injection 
of saline solutions into the colon is many times efficient without 
resort to intravenous injection. If improvement is to take 
place from these injections the pulse should soon become better, 
the brain should clear, and the flow of urine should be increased. 
There may, however, occur a chill and rise in temperature, 
but if the water is freshly distilled and contains nothing but 
the ingredients above named unpleasant symptoms should 
not occur. 

Intravenous injections not only of antitoxins but also of 
certain drugs are sometimes advisable, and the drug most 
frequently so administered is arsphenamine. Quinine dihydro- 
chloride for severe malarial infection, sodium cacodylate for 
severe anemia, and strophanthin for acute heart failure may be 
obtained in sterile ampules for intravenous administration. 
Whatever the drug given it should be in neutral or alkaline 
solution, and of course sterile. The ordinary all-glass hypo- 
dermic syringe may be used for the smaller injections, i.e., for 
strophanthin and quinine. To insure that the needle is in the 
vein, the piston of the syringe should be slightly withdrawn to 
note whether or not a drop of blood appears in the barrel of 
the syringe. 

Occasionally a phlebitis may follow intravenous injections, 
and thrombosis and embolism may rarely occur, but with great 
care there is a minimum of danger from these occurrences. 
Sometimes a slight inflammation is set up in the region of the 
injection and the vein becomes almost occluded; at any rate, it 
may be difficult to use this vein again for subsequent injections. 
This has been noted especially in repeated injections of 
arsphenamine. 

Recently solutions of gum acacia, with or without glucose, 
have been found to be of value when given intravenously, 
and are less likely to cause unpleasant symptoms. 

H YPODERMOCL YSIS 

By this term is meant the introduction of a physiologic 
saline solution into the subcutaneous cellular tissue. Although 
by this method the solution does not reach the general circula- 



TRANSFUSION OF BLOOD 543 

tion as rapidly as by the intravenous method, it often will 
answer the same purpose of supplying needed fluid, and at the 
same time avoids some of the dangers and difficulties of the 
intravenous injection. 

The part of the body best suited for hypodermoclysis is where 
the tissues are loose and there is room for expansion of the subcu- 
taneous cellular tissue, and the location generally selected is 
under the breasts (especially in females), in the subaxillary 
region, or the wall of the abdomen. The skin of the part is 
made sterile (generally by iodine), and the needle is plunged into 
the tissue while the saline is flowing through the tube and needle 
from the reservoir. The reservoir must be two or three feet 
above the part injected, the pressure needed being considerably 
greater than when intravenous injection is given. Not more 
than a pint should be introduced in any one place, except 
possibly in the sub-mammary region in the female. If more 
liquid is to be given by this method, a second site for injection 
must be selected. The fluid should flow slowly, not more 
rapidly than a pint in fifteen minutes. When there is general 
edema or edema of the lungs saline injections are contraindi- 

cated. 

ENTEROCLYSIS 

Colon injections of several pints of warm physiologic saline 
solution or of plain warm water are often advisable in shock, 
and are frequently useful in septic infections, in toxic conditions, 
in drug poisoning, and in severe burns, provided there is no 
edema. 

The "Murphy drip" method of injecting saline solution into 
the bowel, for the purpose of preventing absorption of toxins in 
septic peritonitis by keeping the blood-vessels so saturated 
with fluid that they cannot absorb the purulent exudate, may 
be utilized in other conditions than abdominal sepsis. Some- 
times glucose injections for nutritive purposes are thus admin- 
istered. The technique of this treatment may be learned in the 
surgical clinic. 

TRANSFUSION OF BLOOD 

Transfusion of blood means the transference of blood from 
one individual to another, and direct transference has now 



^44 THE PRINCIPLES OF THERAPEUTICS 

superseded all other methods of procedure, and when done by an 
expert operator (it should rarely be done by any other than one 
who has made a special study of the subject) there is little 
danger to either the donor or the recipient. 

With the greater knowledge of the reactions that may occur 
between the blood of one individual and that of another, it is 
now considered dangerous to transfuse blood from one person to 
another unless the blood from the donor has been tested with a 
small portion of blood of the patient who is to be transfused, to 
determine whether the donor's blood will agglutinate or hemolyze 
the blood of the patient. Also the Wassermann test of the 
donor's blood must be negative. 

The dangers from transfusion of blood, which^have now been 
reduced to a minimum, are that a thrombus be formed; that an 
embolus be introduced into the patient's circulation; that too 
much blood be introduced, to cause dilatation of an already 
weakened heart and heart failure; or that some chemical or 
disturbing reaction occur between the donor's blood and that of 
the patient. This last danger is overcome by previous 
tests; the other dangers are overcome by technique and good 
judgment. 

Reactions in the way of anaphylaxis do not occur in more than 
ten per cent, of the cases under the improved technique. These 
reactions resemble serum sickness with chills, an increase of 
temperature, urticarial rash on the skin, and sometimes a condi- 
tion of shock. 

Various methods have been devised for keeping the blood of 
some suitable donor from coagulating and preserving it for 
transfusion when needed. The anti-coagulants used have been 
herudin (an extract from the leech), and, recently and more 
satisfactory, sodium citrate. There are many advocates for 
the use of the sodium citrate preparations of blood for trans- 
fusion purposes. However, we must record the objections and 
the criticism of this sodium citrate blood offered by the late 
Doctor Edward Lindeman, of New York, who, in an article 1 
which appeared after his death emphatically stated that the 
greatest success with the least disturbance to the patient occurs 

1 Journal A. M. A., June 7, 1919, p. 1661. 



TRANSFUSION OF BLOOD 545 

when the following rules are followed: "(i) the blood must be 
out of the donor's body a minimum length of time; (2) it must 
pass through a minimum amount of foreign material; (3) 
anticoagulants must be avoided; (4) no foreign material, not 
even physiologic sodium chloride solution, should be introduced; 
(5) it must be applicable in any case and in any disease; and (6) 
it must be possible to transfuse in any amount with a minimum 
reaction. " Lindeman, after long laboratory studies and a large 
clinical experience in transfusion, came to the above conclusions. 
He found there is less reaction from blood directly injected 
(provided, of course, the reaction of the donor 's blood to that of 
the recipient had been tested) without any addition to it what- 
soever, either of sodium chloride solutions or sodium citrate 
solutions. He found he could inject larger amounts of blood 
without a reaction than could be done with the sodium citrate 
blood. The greater the amount of blood injected, the more 
likely is there to be a temperature rise, which may occur in from 
two to four hours after the transfusion, and begins to decline in 
from four to eight hours, although Lindeman stated that in his 
last series of 214 consecutive transfusions there had not been a 
single chill, and some cases of pernicious anemia were transfused 
fifteen or twenty times, the only symptoms being a slight rise of 
temperature. 

In subsequent transfusions of a patient, even with the same 
donor, it seems advisable to make repeated agglutination tests 
of the blood. Also, there seems to be more likelihood of anaphy- 
lactic reactions when injections are repeated after an interval 
of ten days to two weeks. During the period of rise in tempera- 
ture there is some feeling of weakness and loss of appetite. At 
other times there may be restlessness and sleeplessness, and rarely, 
in those with a tendency to asthma, bronchospasm may occur. 
It has been estimated by Ashby 1 that the red cells of transfused 
blood may live thirty days or more. 

The exact technique of transfusion can best be learned in the 
clinical laboratory and in the operating room ; consequently it is 
not purposed to describe it here. 

Transfusion of blood is advisable and is life-saving after 

1 Journ. Exp. Med., 1919, xxix, 267. 
35 



546 THE PRINCIPLES OF THERAPEUTICS 

serious hemorrhage, as soon as the bleeding point has been 
sealed. It also is at times advisable before necessary operations 
when much blood has been previously lost. It may be advis- 
able in shock. It has been used in hemophilia and purpura 
hemorrhagica, but these conditions may be as well helped by 
injections of blood serum. It is frequently used in serious blood 
diseases, as leukemia and pernicious anemia. In these condi- 
tions transfusions are given repeatedly, and sometimes with 
success, but it should be recognized that these diseases are prob- 
ably due to infection, and the focus of infection must, if possible, 
be removed. It may be used to prolong life in serious condi- 
tions, as cancer, tuberculosis, and other conditions of denutri- 
tion. It has been of value in some streptococcic infections and 
where there is destruction of blood corpuscles by the streptococcus 
hemolyticus. It has not proved of value in streptococcus viridans 
infection with endocarditis. It has not been proved of 
value in carbonic oxide poisoning, or in such conditions as 
diabetic coma or uremia. 



PART VI 

VACCINES AND SERUMS 

IMMUNITY 

Immunity is (i) natural or biologic, i.e., the normal ability 
of an organism to fight against other organisms that attempt to 
kill it or injure it; (2) or it is inherited; (3) or it is acquired. 

1 . Normally all individuals resist disease and fight off or neu- 
tralize the germs of disease and their toxins, and it is only when 
the individual has a lowered resistance or there is an exceedingly 
large number of disease germs that attack him at one time or 
gain entrance into his organism, that he actually becomes 
infected. In other words, the human being is constantly de- 
stroying pathogenic germs. 

2. Heredity may make the individual immune to certain 
diseases, or at least to modify the intensity of certain diseases. 
Some individuals and some families seem to have inherited an 
ability to withstand certain infections, although they may be 
more susceptible to other kinds of infections. 

3. An acquired immunity is where the individual has become 
infected by germs of a certain disease, has overcome it, and 
afterwards is immune to that particular disease, i.e., he cannot 
again become infected. This immunity may have become ac- 
quired without knowledge on his part; repeated slight infections 
with this particular germ may have raised an immunity against 
that germ, even although he has never been severely infected. 
In other instances he may have the same disease again, but in 
much modified form. The human being may also be inoculated 
with a certain disease, as cow pox, and be afterwards immune to 
its serious relative, small pox ; or, at least, if he becomes infected 
with small pox he will have it in a modified form. Exhaustion, 
debility, or any disease that has depleted his reserve forces makes 
the individual more liable to acquire infections. 

The diseases that generally render permanent immunity, hav- 
ing once been successfully combated, are small pox, scarlet 

547 



548 THE PRINCIPLES OF THERAPEUTICS 

fever, measles, whooping cough, mumps, chicken pox, typhoid 
fever, and probably cholera. On the other hand, influenza, 
pneumonia, diphtheria, erysipelas and streptococcic infection 
seem to render the individual more susceptible to future attacks 
of the same disease. 

In some diseases the germs of infection rapidly spread over 
the body; in others they remain more or less localized, as typic- 
ally seen in diphtheria and tetanus. The germs of these two 
infections secrete poisonous toxins, termed endotoxins, which 
cause serious and dangerous toxemia. Infections, the germs 
or virus of which enter the blood and are thus disseminated, 
are rapid in their destructive processes. Those that are spread 
through the lymph channels are disseminated much more 
slowly, and they may be localized by the protection which the 
lymph glands offer. 

The protections of the body against invasion are: intact 
skin and mucous membranes; normal stomach digestive fluids; 
normal blood and normal serum; and the absence of focal infec- 
tions as they are termed, in the mouth, throat, nose, or other 
part of the body. A focal infection can cause such deteriora- 
tion of the withstand power of the system as to allow other 
infections to occur. Death from infection is generally due to 
destruction of the blood corpuscles, or to the toxins secreted by 
the germs of infection so depressing the circulatory system as 
to cause cardiac failure. 

It is not purposed to more than briefly discuss the protective 
powers of the blood against bacteria. The substances in the 
blood serum that have this protective power have been termed 
broadly alexines. The exact behavior of some of these protect- 
ive bodies or substances has been more particularly termed 
agglutinines, precipitines and lysines. The power of the poly- 
morpholeucocytes to swallow bacteria has been termed phagocy- 
tosis. These leucocytes thus protect from escape the toxins of 
the germs which might cause serious toxemia. On the other 
hand, what has been termed by Wright as opsonin is a sub- 
stance that may stupify or otherwise make the germs of infec- 
tion ready for the phagocytic activity of the leucocytes. 

If an individual is not overwhelmed by the onslaught of a 



IMMUNITY 549 

large number of virulent germs, he begins immediately to manu- 
facture antibodies which will produce an antitoxin against the 
toxins of the infecting germ. If he does not form these anti- 
bodies rapidly or has not these antibodies pre-formed from pre- 
vious infection or from artificial protection, he may be helped, 
in certain diseases, by vaccinations with the dead germs of the 
disease with which he is attacked. These vaccinations stimu- 
late to more rapid formation the antibodies which fight the 
original disease. Later in the disease he should produce anti- 
toxins or protective substances to overcome the toxins produced 
by the dying bacteria. If he cannot elaborate sufficient anti- 
toxin he may succumb to the disease. To help him to immedi- 
ately combat these toxic substances early in the disease anti- 
toxins are administered, and the antitoxin treatment has come 
to be the greatest protective measure that can be offered in 
certain forms of disease. As bacterial science advances, more 
of the infectious diseases will be combated by antitoxic serums, 
though for some of the germ diseases, such as tuberculosis, it 
probably never will be possible to produce antitoxins. 

It has been shown in the laboratory that a certain number of 
antitoxin units will overcome a certain number of toxic units. 
This has been especially demonstrated in diphtheria, and it is 
now known exactly how many units of antitoxin will overcome 
a unit of toxin in a given animal. 

In some diseases antibodies are produced called agglutinins 
which are specific for particular germs. After a patient has 
been ill a week or more with typhoid fever his blood will contain 
an agglutinin that will cause agglutination, or clumping, of live 
typhoid bacilli, when the test is made outside of the body. 
This is the Widal reaction for typhoid fever, and is diagnostic. 
These agglutinin tests are being utilized for diagnosis in other 
infections, as the paratyphoid infections, etc. Also the 
Abderhalden ferment tests are being used to demonstrate the 
presence or absence of many conditions. The Wassermann 
test for syphilis when positive shows that that disease is present ; 
if it is negative it may not show that the disease is absent. 
The gonorrheal complement fixation test when positive demon- 
strates the presence of that infection. 



550 THE PRINCIPLES OP THERAPEUTICS 



ALLERGY 

In the order of their intensity it may be stated that "hyper- 
sensibility" or "sensitization" is the term for the increased 
susceptibility of an individual to a poisonous substance; that 
von Pirquet's term "allergy" means an altered activity or 
altered reaction of the patient, an increased reaction; and that 
"anaphylaxis" is the term for the group of symptoms which 
occur from such a poisonous reaction. This anaphylactic 
reaction is often found as an idiosyncrasy of certain individuals 
to certain drugs or kinds of food, and in its mild form is evi- 
denced by eruptions on the skin, slight increase in temperature, 
more or less gastrointestinal disturbances, often urticarial 
eruptions on the skin, occasionally asthmatic symptoms, and 
a concentrated and irritating urine. 

Certain plant poisons, the pollen's, and sometimes odors from 
certain animals and the dust or odors from certain substances 
cause hay fever and asthma in susceptible individuals. Hay 
fever patients, if possible, must go annually to a region where 
the plants that cause them disturbance do not grow; other 
susceptible individuals must be constantly careful that they do 
not inhale the odors from substances that cause their dis- 
turbance. 

Bacteria, like other living cells, must prepare their food 
for absorption by the formation of ferments. According to 
Vaughan, for a bacterium to be poisonous to a human being it 
must have the ability to split up and feed on human proteins, 
otherwise it cannot grow, and cannot harm the individual. 
Also for bacteria to live and grow the ferments of the human 
body must not be immediately destructive to them, although 
later antibodies may be formed which will destroy them. 
Pathogenic bacteria, therefore, are for a time at least poisonous 
to the human body, unless a previous infection of the individual 
has produced permanent antibodies and therefore immunity. 

If proteins taken into the gastrointestinal canal are properly 
digested and absorbed only in normal molecular forms, poison- 
ing or anaphylactic reaction will not occur. If, however, the 
same proteins or partially digested portions of the proteins 



ALLERGY 55 1 

are absorbed parenterally, i.e., outside of the intestine, poison- 
ing may occur and sensitization and anaphylaxis result. 

Novy and de Kruif 1 state that anaphylatoxin is produced by 
the circulation of the matrix of the poison in the blood. This 
matrix circulating in the blood becomes a poison when any 
alien substance is added to the serum, and many of the simplest 
substances may cause this transformation of the matrix into 
a poison. The sudden development of this anaphylatoxin or 
"taraxin" as these investigators state may bring on the 
explosive symptoms seen in eclampsia and surgical shock, or 
may be the cause of some of the sudden symptoms in auto- 
intoxications, and many of the symptoms of infectious diseases 
are probably caused by the formation of anaphylatoxin. In 
other words, infection leads to "taraxy," as they term it. 
They urge the importance of the consideration that perfectly 
harmless substances in the blood may suddenly, under certain 
conditions, develop this anaphylatoxin and taraxy, and serious 
symptoms may immediately result. 

It has been shown that surgical shock may be caused by 
absorption of muscle juices from the destruction of muscle 
tissue, and hence the condition is one of protein poisoning. 

Typically anaphylaxis is a fever reaction, with rapid heart, 
with flushings of the skin, frequently eruptions on the skin of 
erythema, urticaria, or patches of angioneurotic edema, and 
possibly cerebral excitation. Sometimes in susceptible individ- 
uals very dangerous reactions occur from injections of serum, 
with swelling of the mucous membranes, especially of the 
bronchial tubes, with the development of asthma and dyspnea 
even to the point of suffocation. Such a reaction may be 
immediate, and has occurred when an antitoxin made of horse 
serum was injected into individuals who were susceptible to 
protein poisoning from emanations from the horse. Conse- 
quently, it is unjustifiable to inject a serum prepared from the 
horse into any individual without the knowledge that he is not 
subject to asthma or hay fever from contact with the horse. 
Also any asthmatic patient should be given protein injections 
only with the greatest of care. In such cases, at least, it is 

Journal A. M. A., May 26, 191 7, p. 1524. 



552 THE PRINCIPLES OF THERAPEUTICS 

wise to give an intradermal drop test before the larger injection 
is made to determine the presence or absence of hypersensitive- 
ness to the particular vaccine or serum to be used. 

Some protein poisons cause an increased temperature and 
some a lowered temperature. Those that cause a lowering of the 
temperature are supposed to do so by their ability to dilate the 
peripheral blood-vessels and the blood-vessels of the abdomen 
and to cause congestion of the liver. Consequently, with this 
subnormal temperature there is also a subnormal blood-pressure 
and more or less shock, sometimes termed anaphylactic shock. 

Prevention of Anaphylactic Reaction. — A careful study of 
every patient should be made before injections of horse serums 
or other proteins are given. In all acute conditions the neces- 
sity for carbohydrate food and alkali should be recognized, 
and toxic reactions during serious illness will frequently not 
occur if the development of acidosis is prevented. 

The relation of the endocrine glands to protein poisoning 
should also be considered. An insufficiency of the thyroid 
and parathyroids (both the thyroid and parathyroids may be 
seriously affected by infection) should be considered. At times 
thyroid extract in small doses, or small doses of an iodide should 
be given in both acute and chronic diseases. Also, if there 
are symptoms of muscle, nerve and cerebral irritability, alkalies, 
especially calcium and sodium preparations, should be given to 
counteract the irritability caused by a possible insufficiency of 
the parathyroid glands. 

Non-specific protein therapy is now advocated for many 
conditions. The protein reaction seems to aid in the produc- 
tion of antibodies or antitoxins for the disease that is present. 
Protein injections have been given in chronic infections as well 
as in some acute infections, but their value is still a subject 
for future investigation, and such treatment is not without 
danger. Before injecting vaccines or proteins the possibility of 
lighting up a latent infection must be considered. 

Sensitization. — This is a condition caused by previous injec- 
tion of some protein, and generally does not occur for at least 
a week and perhaps ten days or more after the first injection. 
Consequently, secondary injections of an antitoxic serum after 



PROTEIN POISONING 553 

the lapse of a week or more may cause a serious anaphylactic 
reaction when injections previous to that one have caused no 
such symptoms. 

PROTEIN POISONING— ANAPHYLAXIS 

Allergy, an increased sensitiveness to certain foods may be 
hereditary or acquired, and Schloss 1 summarizes the forms 
which this idiosyncrasy or hypersensitiveness may take as 
urticaria, asthma, shock, angioneurotic edema, erythema 
multiforme, eczema, acute dermatitis, and gastroenteric disturb- 
ances (vomiting and diarrhea). He also notes, as is occasion- 
ally seen, cyclic disturbances of a susceptible individual, with 
the development at intervals of from two weeks to three months 
of one or more of the above signs of poisoning. When there is 
idiosyncrasy against a certain food the patient may be so 
sensitive to it that if that food is added, even in a small amount, 
to any nutriment poisoning will occur. This is particularly 
true of milk and eggs. Sometimes the susceptibility to poison- 
ing from a particular food is outgrown, especially, Schloss says, 
in the congenital type. 

To desensitize a patient to a protein poison hypodermics of 
the substance may be given. This method is satisfactory in 
desensitizing to pollen; but the food proteins are difficult to 
sterilize in solutions that are tolerated by the tissues. 

Schloss has attempted to immunize by feeding, i.e., an ex- 
ceedingly small dose of the offending food is given, even as 
little as 0.002 to 0.005 Gm., in capsule, three times a day, 
either of egg, milk, or other protein. Every day one more cap- 
sule is given (avoiding a reaction), then, after one week, larger 
doses, in capsules, are given, up to 15 to 30 Gm. a day, until 
finally the particular food is given in normal amount. 
This method takes from three to six months to cause desensitiza- 
tion, and after such immunity has been caused the individual 
must take the food daily to keep up his immunity, else it is 
lost, although it is not difficult to again desensitize him. 

Schloss says that while the intracutaneous test for protein 
idiosyncrasy is more sensitive, he believes it often misleading, 
1 American Journal of Diseases of Children, June, 1920, p. 433. 



554 



THE PRINCIPLES OF THERAPEUTICS 



and that the cutaneous test is better. The cutaneous test as 
outlined in the American Journal of the Diseases of Children, 
May j 1920, p. 402, is as follows: "A cut one-eighth of an inch 
long and not deep enough to draw blood is made in the skin 
through a drop of decinormal sodium hydrate solution. 
A small amount of blood is not of consequence. A small quantity 
of dry powdered protein is then mixed with a drop of alkali and 
this in solution comes in contact with the serum of the patient. " 

Schloss finds that protein tests are not satisfactory in patients 
who are suffering acute symptoms of urticaria and asthma. He 
applies a control test near the bend of the elbow on the inner 
surface, which is a very tender region and readily reacts to a 
trauma, and, consequently, makes a valuable comparison with 
the protein test incision. A positive test, is evidenced by an 
urticarial wheal surrounded by a zone of erythema, and Schloss 
states that the wheal is always irregular in outline, and that five 
millimeters or more in size represents a strong reaction. A 
negative reaction does not positively show immunity to the 
protein used, as there may be temporary desensitization. 

To sum up the practical understanding of susceptibility to 
protein poisoning, it may be stated that it is congenital (handed 
down from parent to child) or acquired, and patients who have a 
reaction to such food will also have a cutaneous reaction, if the 
substance is rubbed on an abraded surface. It should, however, 
be noted that a reaction to a skin test with a certain protein does 
not prove that that is the protein or substance that is causing 
the diseased condition either of the skin or other part of the 
body, any more than because a patient has an infected tooth it 
necessarily is the cause of the disturbance from which he is suffer- 
ing. Some patients have an acute eczema when certain foods 
are eaten; others have a chronic eczema due to certain foods. 
Consequently, individuals who do not readily recover from 
eczema should be studied from the standpoint of the skin 
susceptibility to the protein cutaneous test, and any food to 
which they are susceptible should be removed from the diet. 

Treatment. — The treatment of protein poisoning is to with- 
hold the food or drug that caused the condition, to give saline 
purgatives, to insist that large amounts of water be drunk, and 



vaccines 555 

to give alkaline medication. The best alkaline drugs for this 
purpose are sodium bicarbonate and sodium citrate, given in 
sufficient doses and frequently enough repeated to render the 
urine alkaline. Bicarbonate of sodium should be given in a 
dose of 2 Gm. three times a day, and sodium citrate in a dose of 
i Gm. every two hours. Larger doses may be given if symp- 
toms of acidosis are present, such as headache, cerebral 
excitation or delirium. Such a condition may also call for the 
administration of bromides. 

If the offending substance is probably still, in part at least, 
in the stomach, an emetic should be given and if there is much 
intestinal disturbance castor oil may be the best cathartic. If 
the fever is high and the heart action good, one or two doses of 
acetanilid may be advisable. In conditions of shock, besides 
eliminating the poison from the gastrointestinal tract, the 
patient should be surrounded with dry heat and given cardiac 
stimulants, such as atropine, caffeine, and suprarenal or 
pituitary extracts. 

VACCINES 

Vaccines, which are prepared from killed bacteria, when 
injected hypodermatically cause the production of antibodies 
for the particular germs. It is self-evident that an autogenous 
vaccine is of the greatest value. Even autogenous vaccines 
may not cause the antagonistic properties of the blood to act 
upon the bacteria that are causing a superficial infection unless 
the blood supply to that part is sufficient. For this reason 
hyperemic methods applied to surface infections are often of 
value. 

Theoretically it cannot be good judgement or wise to inject 
bacteria to stimulate the production of antibodies or antitoxins 
when the system is already overwhelmed with the infection. If, 
however, the condition is chronic or subacute such stimulant 
bacterial injections may be advisable and therapeutically valu- 
able, as in tuberculosis and chronic gonorrhea. In streptococcic 
infection vaccines are sometimes curative, but more frequently 
they fail. As there are various strains and types of streptococci 
and staphylococci, stock vaccines which represent many organ- 



556 THE PRINCIPLES OF THERAPEUTICS 

isms in order to treat many such infections are much like multi- 
ple mixtures, polypharmacy, and the nostrum treatment of dis- 
ease. Any advantage from such mixtures is probably due to 
the protein contained, i.e., a, non-specific protein treatment. It 
cannot be good treatment to inject a bacterium which the pa- 
tient dose not need to stimulate antibodies against another 
type of germ. Therefore autogenous vaccines made from the 
pus or exudate from the patient's infected areas are much more 
logical. Even these vaccines often fail to be of benefit. Some- 
times the blood is cultured, and if bacteria are found vaccines 
are made from them. 

These autogenous vaccines are sealed in sterile salt solution, 
and should be given in gradually ascending dosage, a slight fever 
reaction showing that the dose is large enough, and much fever 
reaction showing that the next dose should be smaller. Such 
treatment, however, has not produced a large number of favor- 
able results, and the whole subject of vaccine therapy must be 
studied from a more scientific standpoint. In the meantime 
clinicians should use them only in isolated instances. 

In some skin diseases, notably acne, vaccines have been found 
useful; but it should be noted that at the same time the patient 
has been given a more rigid diet, the bowels have been made to 
move properly, often some bowel antiseptic has been adminis- 
tered, and advice given as to the proper care of the skin of the 
face. Bacillus acnes vaccines, in not too large doses, are of 
most value in indurated acnes. 

Some gastrointestinal specialists believe that many of the 
indescribable ills of mankind are due to intestinal intoxication, 
autointoxication as it has been termed, and that this intoxica- 
tion is often due to the bacillus coli. Therefore they have a 
culture made from the stools of the individual and vaccines are 
produced, which when injected into the individual they think 
to be of benefit. However, beneficial results from such treat- 
ment have not been proved, and also it has not been shown that 
such treatment can kill the colon bacillus when it has caused 
infection in the gall-bladder, for instance. 

Protective inoculations against ordinary colds with multiple 
germs, against pneumonic infection with the four or more varie- 



PREVENTION OF SMALL POX 557 

ties of pneumococci, and against influenza with the influenza 
bacilli have not yet. demonstrated their success. 

The doses of the vaccines for various diseases and the exact 
method of administration is fully outlined on the packages in 
which they are bought, but it should be remembered that the 
first dose should be small and subsequent doses at five to ten 
day intervals (the length of time depending upon the reaction) 
must be sufficient to cause a slight fever reaction, but not 
enough to cause anaphylactic symptoms. If such symptoms 
occur, the next dose must be smaller. A single larger first dose 
may be given for focal stimulation to disclose a doubtful or 
concealed focus of infection. 

Protective and Curative Vaccines 
prevention of small pox 

The necessity for protection against small pox and the ability 
of a properly prepared vaccine to prevent the disease requires no 
discussion, as the proof is absolute. In spite of undeniable 
statistics, every physician must be constantly on the alert to 
aid the Department of Health of his State to prevent abolition 
of laws that make vaccination compulsory. 

Every child should be vaccinated before or soon after he 
is six months of age, a preferable time of the year being in the 
cooler months, when there is less perspiration and therefore less 
tendency for associated irritations of the skin to occur. Re- 
vaccination should be done at six or seven years of age, and 
again at any time when there is an epidemic of small pox, or an 
individual is known to have been exposed to the disease. 

The best place for vaccination is on the upper arm, over or 
just above the region of the insertion of the deltoid muscle. In 
the case of girls, vaccination should be done higher up on the 
arm, or it may be done on the calf of the leg or on the outer side 
of the thigh. Vaccination on the leg is likely to cause consider- 
able involvement of the inguinal glands, and therefore some 
temporary disability, provided the child is old enough to walk. 

The skin of the part selected should be thoroughly cleansed 
with soap and water and then washed with alcohol or ether (other 



558 THE PRINCIPLES OP THERAPEUTICS 

antiseptics should not be used). After the alcohol or ether has 
completely evaporated, a drop of virus from a capillary tube 
(from a fresh package that has been kept in an ice chest) is 
expelled (as per directions) upon the cleansed skin. The skin 
of the part is then pulled tense with one hand, while with the 
other hand a scratch is made with a sterilized needle or scarifier 
through the virus about one-quarter of an inch long parallel 
with the arm. This scratch should not draw blood. The virus 
is then rubbed into the abrasion with the side of the needle. 

Another method is to make oblique punctures with the needle 
through the drop of virus so as to carry the virus through the 
outer layer of the skin, the endermal method of vaccination. 
A series of five or six punctures, covering an area of one-eighth 
of an inch in diameter, should be made. These punctures 
should also be made without causing bleeding. 

When vaccination is done by the first method, the moist area 
should be allowed to dry in the air or with the aid of gentle 
fanning, as the part must be thoroughly dry before any clothing 
is allowed to touch the vaccinated area. When vaccination is 
done by the second method, the vaccine or moisture on the 
surface of the skin may be gently removed and the patient may 
be dressed immediately. If the patient is a child, a soft piece 
of linen, as an old handkerchief, may be pinned into the sleeve 
over the vaccinated area so that chaffing may not be caused by 
irritating clothing and also to keep the part clean from outside 
infection. Tight dressings, or so-called vaccination shields, 
should not be allowed. 

If the scab which forms after a successful vaccination is 
injured or falls off before the part is healed, the sore should 
be treated as any other infected area, aseptically, and with 
frequent simple surgical dressings. Large areas of infection 
and hardened tumor masses and swellings of the arm are 
probably invariably due to secondary infection. Aseptic 
surgical management from start to finish should prevent the 
development of any such condition. It should, of course, be 
recognized that unless there is some epidemic emergency, an 
ill, chronically diseased, anemic or marasmic child or individual 
should not be vaccinated during such illness. 



PREVENTION OF TYPHOID FEVER 559 

After primary vaccination the child should be seen at the 
end of a week to note the appearance of the vaccinated area, and 
before that if the vesicle or scab has become injured. 

If it is a secondary vaccination, an immediate reaction may 
occur at the end of twenty-four hours, namely, a redness and 
areola about the spot of vaccination which soon fades away 
without forming a vesicle. This probably shows antibodies in 
the blood and protection from a previous vaccination. If this 
protection is not strong enough for this reaction, there may 
occur, about the fourth or fifth day, a larger areola and a 
minute vesicle which soon disappears. This shows there is 
partial protection. 

Subcutaneous vaccination, by injecting one-half to three- 
quarters of a capillary tube of vaccine diluted with sterile 
water, has been advocated by Goodall 1 on the ground of being 
more aseptic, less likely to become infected, and being less 
painful for children. The effectiveness of this method of 
protection needs demonstration. 

PREVENTION OF TYPHOID AND PARATYPHOID FEVERS 

This subject cannot be better introduced than by quoting 
from Victor C. Vaughan, Jr. 2 who states that typhoid and para- 
typhoid fever occurred in less than o.i per cent, of the American 
Expeditionary Forces, while in the Spanish-American War it 
occurred in 20 per cent, of our soldiers. While the food and 
drink of our men in France were possibly much more carefully 
supervised than in previous wars, the prevention of these 
diseases must be almost entirely laid to protective vaccinations. 

Vaughan studied 270 cases of typhoid fever which occurred 
in patients who had been previously vaccinated against this 
disease, and states that the clinical picture is practically the 
same as in the un vaccinated. The mortality of this series was 
11 per cent. 

Protection against the infection after vaccination does not 
develop until about ten days, and such protection lasts, ordi- 
narily, about two years, although it may last much longer. 

1 Amer. Journ. Med. Sci., Nov., 1919, p. 721. 

2 Journal A. M. A., April 24, 1920, p. 1145. 



560 THE PRINCIPLES OF THERAPEUTICS 

The shortness of the period of protection seems unusual when 
compared with the infrequency with which typhoid fever 
attacks an individual more than once. 

The greatest susceptibility to typhoid fever is in older 
childhood, youth and young adults, although the disease may be 
acquired at any age. Association of large bodies of individuals 
renders the disease more likely to occur, not only because the 
water, milk, or food may become contaminated, but because 
there is frequently some carrier to spread this infection. 

It seems to be demonstrated that all army and navy men, 
nurses, students, all interned individuals in any workhouse, 
asylum or prison, and travellers should be vaccinated against 
typhoid and paratyphoid fevers. Generally three vaccinations 
are necessary at weekly intervals. The first dose should 
represent 500 million killed typhoid bacilli and 375 million each 
of paratyphoid A and paratyphoid B bacilli. The second and 
third injections should each be double this amount, namely, 
1,000 million typhoid bacilli and 750 million each of the para- 
typhoid A and paratyphoid B bacilli. There is often a slight 
reaction to the second injection and sometimes to the third. 
Splendidly prepared sterile packages of these vaccines, with 
sterile syringes, can be obtained for private practice. These 
injections must be given subcutaneously. Needless to say all 
vaccine preparations must be fresh and must be kept on ice 
until used. A single injection of antityphoid vaccine has been 
developed, but it does not seem to be an improvement on the 
above method. 

PREVENTION AND TREATMENT OF WHOOPING COUGH 

It is generally agreed that the cause of pertussis is the 
Bordet-Gengou bacillus, and vaccination with preparations of 
this germ seems to be of sufficient value to cause its clinical 
study. Protective injections are given to children who have 
not had the disease when there has been an epidemic or when 
they have been exposed to the infection. It has been thought, 
also, that when injected into children who had the disease the 
symptoms were milder and the duration of the disease shorter. 

To immunize a child a dose of 200 million bacilli, repeated 



TREATMENT OF TUBERCULOSIS 56 1 

about four times, has been considered by some observers to be 
sufficient. As a therapeutic measure after the disease has 
developed very much larger doses of killed bacilli may be 
used, but the exact value of such treatment has not been 
demonstrated. 

PREVENTION OF HAY FEVER 

If in hay fever a particular vegetable protein is known to 
be the cause, or has been discovered by skin or intradermal 
tests, vaccination with this protein extract to prevent the 
development of the disease has shown some success. To be 
successful the injections must be begun at least eight weeks 
before the hay fever generally begins in the particular patient, 
and a series of injections must be given. The dose to begin with 
must be very small and then gradually increased, the injections 
being given at intervals of a few days. From ten to fifteen 
injections are generally necessary. Such treatment has pre- 
vented some patients from having an attack on that particular 
year and sometimes the following year, but their susceptibility 
is likely to re-develop at least by the third year, and they then 
require another series of injections. If anaphylactic symptoms 
develop during the treatment, the injections must be tempo- 
rarily stopped, and later a smaller dose given. About thirty 
pollen extracts from plants and flowers may be obtained for 
tests and for prophylactic treatment. 

TREATMENT OF TUBERCULOSIS 

There are several preparations of tuberculin, the old tuber- 
culin designated as O.T., which is made from human tubercle 
bacilli; tuberculin residue (tuberculin rest) designated as T.R., 
which is made by a special treatment of the tubercle bacilli, 
and which is the preparation most used for therapeutic pur- 
poses; a bouillon filtrate tuberculin, designated as B.F., which 
is prepared from the old tuberculin; and the tuberculin bacillin 
emulsion, designated as B.E., which is also used for therapeutic 
purposes. 

The preparation termed O.T. is the one generally used as a 
diagnostic test, and, when injected in a small amount, a positive 

36 



562 THE PRINCIPLES OP THERAPEUTICS 

reaction is a reliable test in children and adults; but a negative 
test in adults may not show the absence of all tuberculous 
infection. The beginning dose should be very small, namely, 
0.0001 Gm.; the second dose should be increased to 0.001 Gm., 
the third to 0.003 Gm., the fourth to 0.005 Gm., and the fifth 
to 0.006 Gm. The patient who does not react to the 0.005 and 
0.006 Gm. doses should be considered non-tuberculous. If a 
reaction occurs at any smaller dosage of course further injec- 
tions are unnecessary. 

These injections cause a leucocytosis and stimulate the pro- 
duction of ferments in the tissues immediately surrounding the 
tubercles. A rise of temperature is caused when the toxins 
around the tubercles are set free by the action of these enzymes. 

When a tuberculin is used as a therapeutic measure these 
reactions caused by the liberation of the toxins in the tubercles 
should generally be less and less until such reactions cease. 
The very fact that tuberculin can cause such liberation of toxins 
and even perhaps of living bacilli shows the danger of large 
doses of tuberculin at any time and for any purpose. 

The treatment of tuberculosis with tuberculin is not on the 
increase, although some specialists in this disease have con- 
tinued to use it and state that they have continued good results. 
While most experts in tuberculosis believe that tuberculin 
should never be given as long as there is active fever from the 
disease, especially if that fever lasts throughout the twenty-four 
hours, a few specialists believe that a small amount of tempera- 
ture dose not preclude the use of this agent. 

Tuberculin injections should be given only when the patient 
is at rest, and the best hour is 9 P.M., when the reaction of a 
rise of temperature will be noted early in the morning. A focal 
reaction is evidenced by pain or disturbance in a joint or other 
suspected area or by the evidence of moist rales and congestion 
in suspected parts of the lungs. 

Tuberculin for therapeutic purposes is not infrequently 
indicated in laryngeal tuberculosis, in joint tuberculosis, in 
kidney tuberculosis; and in pulmonary tuberculosis when the 
disease has progressed to a certain stage of improvement and 
then remains stationary. However, it is quite possible that 



BOILS AND CARBUNCLES 563 

the various heliotherapeutic measures may prevent the necessity 
for the tuberculin treatment. 

The von Pirquet tuberculin test is a vaccination test. It is 
made by scarifying two minute areas and rubbing into them a 
drop or two of O.T. solution, which may be obtained in glass 
tubes for that purpose. A control spot should be scarified and 
treated with a drop or two of glycerin and water. In about 
twenty-four hours, sometimes less, sometimes more, the tuber- 
culin treated areas should show a reddened areola much greater 
than the control spot, if the test is positive. The test is, how- 
ever, of but little value except during childhood, as it is fre- 
quently positive in apparently healthy older children and adults, 
showing that somewhere, sometime, they have probably had a 
tuberculous infection. 

The Moro skin test is made by rubbing a minute part of old 
tuberculin combined with a small amount of ointment, as lard 
or lanolin, into a small area on the abdomen. The reaction 
showing tuberculosis to be present is represented by an ery- 
thema with an eruption of several papules which appear in 
twenty-four to forty-eight hours. 

Intradermal tests are also made with a minute amount of 
tuberculin, with control intradermal punctures. 

TREATMENT OF GONORRHEA 

In the acute disease Neisser vaccines have not proved of 
value, but in chronic gonorrhea, especially when the disease is 
localized in some organ, and even in acute gonorrheal conjuncti- 
vitis these vaccines seem to be of value. 

TREATMENT OF BOILS AND CARBUNCLES 

A series of boils and carbuncles occurring in a patient shows 
that infection, emanating from some internal focus or having 
entered the individual from some injury, is probably circula- 
ting in his blood and causing these multiple troubles. If, after 
the focus of infection has been eliminated, or the external in- 
fected area healed, and iron, tonics, and perhaps yeast have 
been administered, the boils or carbuncles still recur, an autog- 
enous streptococcic or staphylococcic vaccine should be tried. 



564 THE PRINCIPLES OF THERAPEUTICS 

PREVENTION OF RABIES 
HYDROPHOBIA 

The efficiency of antirabic vaccine has now long been demon- 
strated. Consequently, as soon as an individual has been 
bitten by a dog know or supposed to be "mad" the Pasteur pro- 
tective inoculations should be begun at once, i.e., before the 
bacteriologic laboratory test has demonstrated the presence of 
negri bodies in the dog's brain or cord. Also the negri bodies 
may be absent from a specimen and yet the dog have rabies. 
Injections of antirabic vaccine are given daily for twenty days 
with a gradually increasing strength of the vaccine. The 
injections are best given in the abdominal walls. Although full 
immunity is probably not developed until about two weeks later, 
still protection is generally caused, as the incubation period of 
the hydrophobic virus is rarely less than three weeks and gener- 
ally much longer, perhaps forty days on an average. Bites on 
the face, probably because nearer the brain, show a shorter 
incubation period than bites on other parts of the body. 

The bitten individual may be sent immediately for treat- 
ment to a Pasteur Institute, or the vaccine may be obtained 
from the laboratory and the patient may be treated by his 
physician at his own home. 

PROTECTIVE AND CURATIVE SERUMS 
ANTITOXINS 

The following are official antitoxic serums: 

Serum Antidiphthericum is a solution of which the average 
subcutaneous or intramuscular therapeutic dose is 10,000 
units, and the average protective dose is 1,000 units. 

Serum Antidiphthericum Purificatum is a solution of antidiph- 
theric globulins, the dose of which is the same as the preceding 
preparation. 

Serum Antidiphthericum Siccum is a dried antidiphtheric 
serum which will keep well under varying conditions of tempera- 
ture and travel. The dose is the same as the above, and it is 
prepared for injection by dissolving it in physiologic sodium 
chloride solution. 



ANTITOXINS 565 

Serum Antitetanicum is a solution of which the average subcu- 
taneous and intramuscular dose is 10,000 units and the average 
protective dose 1,500 units. 

Serum Antitetanicum Purificatum consists of antitetanic 
globulins, and the dose is the same as the preceding preparation. 

Serum Antitetanicum Siccum is a dried antitetanic serum 
which has good keeping properties and is prepared for injection 
by dissolving it in physiologic sodium chloride solution. The 
dose is the same as the above. 

The following serums are recognized byN.N.R., edition of 
1920: Antianthrax Serum; Antidysenteric Serum; Antigono- 
coccus Serum; Antimeningococcus Serum; Antipneumococcus 
Serum; and an Antistreptococcus Serum. 

It has been found that the antitoxic properties of antitoxic 
serums are in the globulins, therefore with these concentrated or 
purified serums the bulk of the dose is smaller though the anti- 
toxic units are the same. 

When using any antiserum it should be remembered that 
severe anaphylactic symptoms may occur from repeated injec- 
tions any time subsequent to seven days after the first injection. 
The patient becomes sensitized and more or less intense reaction 
to subsequent protein injections is likely to occur. Therefore 
injections of antiserums given seven days or more after the 
first injection require careful decision of the necessity for the 
risk, and the dose injected should not be large. 

Whenever any antitoxin made from horse serum is to be 
injected into an individual it should be known that he is not 
susceptible to horse emanations, as evidenced by the develop- 
ment of hay fever or asthma when such emanations are inhaled, 
as serious symptoms and even death may occur. In fact, any 
individual subject to asthma attacks should be given serums 
with the greatest circumspection. 

Antitoxins are best given subcutaneously where the tissues 
are lax, either in the sub-axillary region or in the abdominal wall. 
Blood-vessels and nerves should be avoided as is usual in giving 
all injections, and the care as to cleanliness and to sealing the 
puncture with collodion after withdrawal of the needle is the 
same as with all treatments that require puncture of the skin. 



^66 THE PRINCIPLES OF THERAPEUTICS 

PREVENTION AND TREATMENT OF DIPHTHERIA 

The wonderful results of the antitoxin treatment of diphtheria 
during the last twenty-five years is shown by the fact that a 
mortality of not far from 30 per cent, has been reduced to a mor- 
tality of less than 8 per cent., and were the diagnosis of the 
disease always made within the first twenty-four hours and anti- 
toxin immediately given, it is probable that the mortality would 
be reduced to zero. The antitoxin treatment of diphtheria 
must be considered one of the greatest medical successes of the 
age. Unfortunately the same cannot be said of antitoxin for 
other diseases. Not only will antitoxin cure diphtheria, but 
when given soon enough will prevent the occurrence of diphthe- 
ria in those who have been exposed to the disease. 

As a large number of individuals are immune to diphtheria, 
it was of the greatest consequence for a test to be developed to 
demonstrate whether or not an individual is susceptible to the 
disease. Therefore by means of this test many individuals who 
otherwise must receive preventive injections need not now 
receive such treatment. 

The test referred to is the Schick test, which consists of in- 
jecting }£ of a minimum fatal dose of diphtheria toxin for a 
250 gram guineapig into the skin and noting the reaction which 
occurs in from twenty-four to forty-eight hours. Earlier reac- 
tions are not considered positive. A positive reaction consists 
of a circumscribed area of redness and slight swelling measur- 
ing from 1 to 2.5 centimeters in diameter. The local redness 
and swelling will increase in intensity for three or four days and 
may persist for a week, leaving a brown pigmentation which 
later generally scales. A positive reaction indicates that the 
individual has less than the required amount of antitoxin in his 
blood to prevent the development of diphtheria, if he becomes 
infected. Such persons are susceptible to diphtheria, and when 
they have come in contact with the disease should receive pre- 
ventive injections of the antiserum. Schick, and later Park, 
found that about 80 per cent, of new-born babes, more than 
50 per cent, of all children, and about 90 per cent, of adults 
contain sufficient antibodies in their blood to protect them 
against the development of diphtheria. 



DIPHTHERIA ANTITOXIN 567 

Blum 1 made the Schick test on 1,076 children in an institution 
during a period of five years, and found that a negative Schick 
test was evidence of the presence of sufficient antitoxin to pro- 
tect the child against diphtheria. Modified reactions showed 
only a small amount of such protective antitoxin. Infants 
under six months of age have a transmitted immunity which a 
certain number lose after three years of age, but Blum believes 
that an institution may be made diphtheria-free by the 
Schick test and the injection of toxin-antitoxin into those 
who show that they are not immune to the disease. The 
duration of immunity caused by such injections has not been 
ascertained. 

Schick believes that 100 units of antitoxin per kilogram of 
weight is sufficient to combat the toxin of diphtheria in an ordi- 
nary case, while in severe cases 500 units per kilogram (23^5 
pounds) is more than sufficient. The earlier in the disease the 
dose is administered, the smaller the dose that is required. 
While there has been a great deal of discussion as to the num- 
ber of units required, many clinicians believing in enormous 
dosage, the amount should probably range from 4000 units in 
the beginning of a mild case of diphtheria to 20,000 units in a 
severe case, and more in nasopharyngeal and laryngeal types. 
These doses are sufficient for a child. The doses for an adult 
should be larger, ranging from 6,000 to 30,000 units. 

Park finds that when antitoxin is given subcutaneously it 
takes twenty-four hours before the maximum amount of anti- 
toxin is circulating in the blood, while if the antitoxin is given 
intramuscularly the period is greatly shortened. In severe 
cases it should be given intravenously. 

The average immunizing dose for a child, who has been shown 
by the Schick test to be susceptible to the disease and who has 
been exposed to diphtheria is 1,000 units. The protection 
lasts, according to Park, from two to four weeks. 

The globulin concentrated antitoxins are probably the best 
preparations, as the amount required for injection is much less 
than of the ordinary antitoxins. 

1 Amer. Journ. Dis. Child., July, 1920, p. 22. 



568 THE PRINCIPLES OF THERAPEUTICS 

PREVENTION AND TREATMENT OF TETANUS 

The tetanus toxin or virus is absorbed from the point of 
infection by the peripheral nerve tissues and ascends through 
the nerve trunks to the spinal cord by way of the axis cylinder 
of the motor nerves. It may also be transported by means 
of the perineural lymphatics. 

The greatest value of the tetanus antitoxin is when it is 
administered before symptoms of the disease have developed; 
after the infection has reached the spinal cord the success of any 
treatment is limited. During the war wounded or injured men 
were immediately given antitoxin injections, and the local 
injury, besides surgical cleaning, was also treated with anti- 
toxin solutions and powdered antitoxin. The prophylactic dose 
is about 1,000 units, given subcutaneously, and preferably at 
or near the region of the injury. Frequently it is advisable 
to repeat the dose within a few days; also, as just stated, the 
serum or the antitoxic powder, dissolved, should be injected 
into and around the injured region. 

As in administering antitoxin for diphtheria, individuals who 
are susceptible to the emanations of the horse or who are sub- 
ject to asthma and hay fever should not be given the injections 
of antitoxin, although the wound might be locally treated with 
dried serum. 

If tetanus has developed, massive doses of antitoxin should 
be administered intraspinally, and also intravenous injections 
should be given. The intraspinous injections may be repeated 
every twelve hours, for two or three doses, if deemed advisable. 
Later subcutaneous injections should be given daily for three 
or four days. 

TREATMENT OF PNEUMONIA 

At the present time it seems demonstrated that antipneu- 
mococcic serum of type I pneumococcus should be given as soon 
as the diagnosis of pneumonic infection has been made. If the 
pneumonia, which so frequently is of a mixed type, is mostly 
due to other types than type I pneumococcus, the serum will 
do no harm, but if the disease is due to type I, this serum seems 
to prevent serious symptoms and may even abort the inflam- 



LUMBAR PUNCTURE 569 

mation. Though this antiserum is generally administered 
subcutaneously, Cole advises giving 90 to 100 c.c., every eight 
hours, intravenously until the temperature falls. 

A serum for type II has not proved successful, and there are 
no anti-serums for types III and the group termed type IV. 

TREATMENT OF BACILLARY DYSENTERY 

A mixed antidysenteric serum may be obtained for bacillary 
dysentery for both the Shiga and the Flexner types. Sub- 
cutaneously the adult dose is about 20 c.c, repeated a few 
times at twenty-four hour intervals. In severe cases it should 
be given intravenously in about 50 c.c. doses. This serum is 
most active when given early in the disease, and is of no 
value in other forms of dysentery. 

LUMBAR PUNCTURE 

This procedure is used for diagnostic purposes, to relieve 
pressure in the cerebrospinal canal, for treatment, and to pro- 
duce anesthesia. For diagnostic purposes spinal puncture is 
done to determine what kind of cerebrospinal inflammation is 
present, generally to differentiate between cerebrospinal (menin- 
gococcic inflammation), pneumococcic, septic, and tuberculous 
meningitis, and at times to determine the presence of anterior 
poliomyelitis and for the Wassermann test for syphilis. 

Levinson 1 states that " there are three types of conditions 
that produce changes in the cerebrospinal fluid: meningism, 
meningitis, and systemic disturbances. The meningismal 
changes manifest themselves in an increase in pressure and 
amount of the fluid. Occasionally there are also cytologic and 
chemical changes." He finds no evidence of acidosis in the 
cerebrospinal fluid of meningism, and believes that the pro- 
duction of meningism is mechanical, due to an increase of blood- 
pressure in the head. 

Herrick 2 after reviewing the literature and making a personal 
study of 76 cases of acute disease not resulting in meningitis, 
finds "that the cerebrospinal fluid often gives evidence in in- 

1 Amer. Journ. Dis. Child., Dec, 1919, p. 568. 

2 The Journal A. M. A., Nov. 1, 1919, p. 1321. 



570 THE PRINCIPLES OE THERAPEUTICS 

creased pressure, pleocytosis and heightened globulin content 
of a reaction on the part of the leptomeninges to the infective 
agents or toxins of a large number of miscellaneous acute dis- 
eases not ordinarily causing true meningitis. " 

Evidences of disturbances of the cerebrospinal fluid may 
occur not only in severe illness, as typhoid fever, pneumonia, 
and sepsis, but in tonsillitis, measles, mumps, arthritis, and 
even in the condition of migraine. 

Herrick found the cerebrospinal fluid to show changes in 
about one-third of the cases studied, and when there were 
changes there were not necessarily meningismus symptoms, 
and, on the other hand, meningismus could occur without 
pronounced changes in the cerebrospinal fluid. He further 
states that the greatest caution should be used in making a 
diagnosis of meningitis or poliomyelitis from fever, meningismus, 
and changes in the cerebrospinal fluid, and believes that when 
there are less than ioo cells per cubic millimeter of spinal fluid 
the presence of these diseases is doubtful " unless clinical epi- 
demiologic or other laboratory evidence is decisive. " 

In making a diagnosis of the condition from the spinal fluid 
it should be noted that normal spinal fluid contains ten cells 
per cubic millimeter. In cerebrospinal meningitis (meningo- 
coccic meningitis) the diplococcus intracellularis meningitidis 
is found in the spinal fluid, and the fluid withdrawn is cloudy. 
In anterior poliomyelitis the fluid withdrawn is clear, and the 
cells are increased to twenty or more, even to as many as a 
hundred per cubic millimeter, but as cautioned by Herrick 
diagnoses from the cell count must be made cautiously. In 
tuberculous meningitis the fluid is clear, and there is an increase 
in small mononuclear leucocytes (lymphocytes). In pneumo- 
coccic infection the fluid is turbid and may be even yellowish. 

The speed with which the fluid flows out through the needle 
shows the pressure of the fluid in the cerebrospinal canal. The 
quantity of fluid that should be withdrawn varies from 10 mils 
in young children to 20 mils or even, in certain cases, to as much 
as 50 mils in the adult. 

In the antitoxic treatment of meningococcic meningitis 
the amount injected should be from 5 to 10 mils less than the 



LUMBAR PUNCTURE 571 

amount of fluid withdrawn, and the dose of the antitoxin may- 
be from 20 to 40 mils in the adult, and from 3 to 20 mils in 
children. 

In many serious conditions cerebral symptoms are often 
present on account of an excessive exudate or of an increased 
amount of fluid in the cerebrospinal canal. Lumbar puncture 
to relieve pressure is many times a valuable therapeutic measure 
in many forms of coma. 

Whatever the cause for the removal of spinal fluid "puncture 
headache" may occur, though often not until the day after the 
fluid has been withdrawn. It is generally not serious, is 
located all over the head, and may last for several days; it is 
likely to occur when there is low pressure in the cerebrospinal 
canal even though but little fluid was withdrawn. The fluid 
should be withdrawn very slowly, and the patient should remain 
on his back for several days, to prevent this unpleasant 
symptom. 

Lumbar puncture may be done with the patient sitting up 
and leaning over; or he may lie on his left side with the knees 
drawn up, the object being to make as wide a space as possible 
between the third and fourth, or fourth and fifth lumbar 
vertebrae, which are the best regions for puncture. If the 
vertebrae cannot be readily counted, a line drawn from the 
crest of one ilium to the crest of the other will give the level at 
which the puncture should be made. The skin is painted with 
tincture of iodine, and the whole operation should be done 
under aseptic methods. The proper needle, the size depending 
on the age of the patient, should be plunged inward and slightly 
upward from the central point between the vertebrae. The 
distance into the subarachnoid space varies from a little less 
than an inch in young children to an inch and a half, or a little 
more, in adults. As soon as the canal has been entered, the 
spinal fluid should flow, and it should be received into a sterile 
test tube. The force with which the fluid spurts depends on 
the pressure in the spinal canal. 

If the puncture is dry and no fluid flows, it may be because 
the canal has not been entered; or it may be because there is 
some plugging of the canal at some part by exudate or some 



57 2 THE PRINCIPLES OF THERAPEUTICS 

kind of a clot. In such cases, if meningococcic meningitis is 
present, the serum may be injected into the ventricles of the 
child, care being taken not to increase the pressure so as to 
affect the respiration and pulse. 

Occasionally, after the injection of serum, the respiration may 
be disturbed and the patient be in a condition of shock, the 
pulse small and the face pale. If this occurs while the injection is 
being given, some fluid should be allowed to run out of the canula. 
The gravity method, with very slight pressure is the only method 
that should be used in giving these injections. If shock really 
has occurred, artificial respiration should be done and atropine 
and epinephrine should be given hypodermatically. 

When the symptoms show, in meningitis, that more antitoxin 
must be given (in cerebrospinal meningitis it should be given 
every twelve hours until the patient shows improvement, and 
then every twenty-four hours until the patient is apparently 
convalescent) the patient should lie on one side for one puncture 
and on the other side for the next puncture, so that the fluid 
in the lateral ventricles may better flow toward the spinal canal. 

Lumbar puncture is often done to determine the presence or 
absence of syphilis by a Wassermann test of the spinal fluid. 
This test is often positive when the blood test is negative. 
Arsphenamine solutions are frequently given intraspinally for 
the treatment of cerebrospinal syphilis. It should be remem- 
bered that this is an arsenic treatment and may cause muscle 
pains, headaches, irritation of the kidneys, and possibly cause 
optic or aural neuritis. Arsphenaminized serum is also in- 
jected into the spinal canal. This spinal arsenical treatment of 
cerebrospinal syphilis will probably be less frequently utilized 
since it has been found that arsenic given intravenously reaches 
the cerebrospinal fluid. 

Lumbar puncture should be considered a serious and not a 
simple procedure. Consequently, with every case of slight 
head symptoms or even a beginning meningismus, lumbar 
puncture should not necessarily be immediately done. It 
requires a careful decision on the part of the physician and 
perhaps of a consultant to decide that this operation is neces- 
sary for diagnostic purposes. 



CEREBROSPINAL MENINGITIS 573 

Wegeforth and Latham 1 have recently shown that in septic 
conditions, without infection in the brain, lumbar puncture with 
the withdrawal of considerable fluid has perhaps, by too great 
negative pressure in the cerebrospinal canal, allowed the in- 
fection to spread to the meninges. They suggest that before 
such lumbar puncture a blood culture be made, and, if lumbar 
puncture is considered necessary, but a small amount of liquid 
be withdrawn, so as to minimize the possibility of this accident 
of unnecessary infection occurring. While such cases of 
meningeal poisoning from this reason may be very rare, it still 
does not militate against the necessity of always considering 
lumbar puncture a more than simple operation. 

TREATMENT OF CEREBROSPINAL MENINGITIS 

The cause of epidemic meningitis is the diplococcus intracel- 
lularis meningitidis, also called the meningococcus. Doubtless 
the sporadic form of this disease often termed basilar meningitis 
is frequently due to the same germ. 

Although antimeningococcic serum was not recognized in the 
last revision of the Pharmacopoeia, the value of this treatment 
is positive. It has greatly reduced the mortality, and pre- 
vents some of the serious sequellae following an attack of this 
disease. When the analysis of fluid withdrawn from the spinal 
canal shows that this disease is present, this antiserum should 
be injected in an amount of 5 to 10 mils less than the fluid 
withdrawn. The dose for an adult is ordinarily from 30 to 50 
mils, and for infants and children from 5 to 20 mils. The 
antiserum should be given daily until the spinal fluid is free 
of germs. It has been suggested that antimeningococcic serum 
be also given subcutaneously. When the disease is severe, the 
serum may be given intraspinally every twelve hours for a few 
times. In mild cases once in twenty-four hours for four days is 
generally sufficient. All injections of fluid into the spinal canal 
should be given slowly and before the withdrawal of the needle 
the patient should be watched to note whether immediate 
symptoms of shock occur or there is much disturbance of the 
respiration. If shock or pressure symptoms occur fluid should 

1 Amer. Journ. Med. Sci., Aug., 1919, p. 183. 



574 THE principles or therapeutics 

be allowed to flow out of the canal. Hypodermic cardiac 
stimulation may be given if needed, and artificial respiration is 
occasionally necessary. Epinephrine solutions may be given 
intramuscularly, and seem to counteract this kind of shock. 
Fortunately, with good technique and with the small amount 
of fluid now injected, these symptoms rarely occur. 

TREATMENT OF ANTERIOR POLIOMYELITIS 

As yet there has not been developed a specific antiserum 
for this disease, but the blood serum of an individual who has 
had poliomyelitis, when injected into the spinal canal, has seemed 
to greatly modify the symptoms and diminish the seriousness of 
the sequellae. The more recent the recovery from this disease, 
the more effective is the serum. The usual examination of the 
patient who is to be the donor of the serum must, of course, be 
made, namely, there must be no chronic disease present, and the 
Wassermann reaction must be negative. Such serum has been 
given intravenously as well as intraspinally. The amount given 
intraspinally is about 20 c.c, and much less to very young 
children. It may be given daily for several doses, but Amoss 
says it is of doubtful value after the febrile stage. 

Rosenow has prepared a serum from the horse by immunizing 
him with the coccus found in the central nervous system in 
epidemic poliomyelitis. This antiserum has been used for 
protective and curative purposes, and certainly deserves 
further study and more clinical tests. Some recent clinical 
reports have apparently shown a reduction in the mortality of 
this disease when patients were treated with this antiserum. 

TREATMENT OF CHOREA 

This disease, though generally mild, may be very serious and 
fatal. Consequently, a recent report of a successful serum 
treatment is of sufficient interest to be recorded. Block 1 reports 
that both he and several colleagues have successfully treated 
serious cases of chorea by the following method: From 20 to 
30 mils of fluid is withdrawn from the spinal canal of these 
patients into sterile tubes. These tubes are then kept on ice, 

1 New York Medical Journal, May 29, 1020, p. 949. 



TREATMENT OE CHOREA 575 

and in severe cases of chorea twice daily 2 mils are administered 
subcutaneously with the ordinary hypodermic syringe. Im- 
provement did not occur in a series of cases when the spinal 
fluid alone was withdrawn, but did occur when such fluid was 
injected subcutaneously in the dose mentioned. The final 
standing of this treatment can only be shown by future clinical 
test. 



PART VII 
FOODS AND DIETS 

The discussion of this subject is from the broad standpoint 
of the need of the body for the various elements of nutrition. 
It is also purposed to outline the values and uses of the various 
foods, but it is not intended to discuss the physiology of nutri- 
tion more than to state the fundamental basic principles for the 
practical advice given. A few facts are presented that every 
practitioner must know in order to properly treat his patients, 
as the age of "drugging" is past. It must now be the object 
of every physician to modify, if possible, disturbances of the 
system by changes in the food and drink before drugs are called 
upon for aid. As elsewhere stated, the better the clinician 
understands physiology, the better therapist he is. 

Growth and body up-keep depend largely upon proteins; 
energy (work, heat, and physiologic activities) depends upon 
carbohydrates, sugar and fats. Salts are necessary for tissue 
building and for other chemical interaction of the body. Water 
is needed for tissue building, for circulation, for digestion, for 
most physiologic processes, for eh'mination of waste products, 
and for the necessary loss of heat. 

Any exercise no matter how slight, even the difference be- 
tween sitting and lying, increases the need for energy-giving 
foods. Growing boys and girls require about 25 per cent, more 
food, relatively, to their weight, than do adults, especially the 
energy foods. Men require more food than women; large men 
(not fat men) require more than small men, though a small man 
may require relatively more food than a large man. The more 
the exercise, the more the energy food required. An individual 
with fever requires more energy foods than when he is well and 
at rest, though ordinarily not as much as when he is well and at 
work. 

The unit of measure of the fuel value or energy content of 
foods is the calorie, which is the amount of heat required to 

576 



FOODS AND DIETS 577 

raise the temperature of a kilogram of water i degree Centi- 
grade. The energy value of all foods is measured by this unit. 
A man weighing 150 pounds requires food yielding about 2500 
calories per day, if his work is largely sitting and he does no ac- 
tive labor. The more standing or other simple exercise, as well 
as the more the physical labor, the more calories needed, up 
to the prolonged physical exertion requirement of 6000 calories, 
or even more, per day. The average daily need is about 3000 
calories. 

It is obvious in instances of loss of weight, loss of strength, 
and lack of growth of children, that the age and life habits must 
be considered by the physician, and the diet of the individual 
must be carefully studied before a decision is made as to the 
change of food required. Also in cases of overweight and mal- 
metabolism the same investigations must be made, and the diet 
modified according to its defects. The babe must have a prop- 
erly balanced diet not only for his present health, good diges- 
tion, and immediate proper growth, but also to insure future 
normal endocrine gland activity, proper growth and health of 
his hair and teeth, and the normal development of puberty. 

Hunger sensations are due to contractions of the stomach. 
Smoking, sweets, water, and disagreeable odors just before meals 
inhibit appetite. Mental depression stops appetite. The 
sight and smell of good food, or even the thought of palatable 
food stimulates the gastric secretions and promotes appetite. 
Good cheer promotes appetite and digestion. Generally the 
desire for a certain kind of food or a craving for that food in 
health represents a body need for nutriment of that character. 
Of course this does not mean that the desire for such food as 
appeals to the child's eye is a good indicator of what he really 
needs. 

There is much over-eating of protein food, but not to the 
extent of former days. The causes of the smaller amount of 
protein intake are many, namely : civilization ; education ; higher 
art of cooking; less hardship; more variety of food; the greater 
recognition that large amounts of protein do not increase 
energy but rather decrease it; the increase of diseases of the 

organs of elimination which make end-products of protein 

37 



57S THE PRINCIPLES OF THERAPEUTICS 

metabolism difficult of excretion ; and, finally, the relatively high 
cost of animal protein foods. All of these causes have played 
important parts in the diminished consumption of protein, 
and especially of animal protein, foods. 

The amount of protein foods required and its character, 
animal or vegetable, depends largely upon the climate. The 
colder the climate, the more the animal proteins and fat required; 
the warmer the climate, the less proteins, especially animal 
proteins, required, and the more fruit acids needed. 

The protein of tissues is a fixed part of the body, and it is 
changed and lost from the body very slowly. Carbohydrates 
do not become a part of tissue, unless the stored glycogen may 
be so considered. 

It has been estimated that an adult weighing about 150 
pounds, working moderately eight hours a day, requires a 
minimum of 100 to 120 grams of protein, about 50 grams of fat, 
about 500 grams of carbohydrate, 2 quarts of water, and fre- 
quently takes about 1 2 grams of sodium chloride, a day. It is 
not wise for the intake of the individual to be too close to the 
minimum; it is better for him to have a daily reserve, even if 
the extra food is not required. If one type of food is diminished, 
generally the other types should be increased. 

PROTEINS 

An active man requires from 100 to 120 grams of protein per 
day. A protein is a food that contains not only the ordinary 
elements carbon, hydrogen and oxygen, but also nitrogen. 
Roughly they contain about 50 per cent, of carbon, about 16 
per cent, of nitrogen, about 23 per cent, of oxygen and a little 
sulphur. There are animal proteins and vegetable proteins, 
and although some races live and thrive on the latter, and some 
diseased conditions are improved by a total abstinence from 
animal protein, nevertheless, man in most climates remains 
in better, sturdier health, and is better able to withstand 
disease on a properly balanced mixed protein diet. 

However, it may be a fact, though not yet demonstrated, 
that a child, in this climate for instance, who has been brought 
to adult life without ever having had animal protein (meat, 



PROTEINS 579 

fish, and poultry) may be as equally fitted to enjoy health and 
withstand disease as is the individual who has eaten meat 
throughout his life. It should be emphasized that, on account 
of the inherited and acquired ability to metabolize animal 
proteins, there must be many changes in the body for it to 
adjust itself to as efficiently metabolize vegetable proteins to 
the needs of the system, when a radical change is made from 
animal to vegetable proteins. Such a change may be likened to 
changing the fuel of a furnace from hard to soft coal without 
changing the grates, drafts, and the frequency and amount of 
fuel given the furnace. The necessity for the above caution 
against radical changes in diet must be recognized when we 
know that the amino acids of animal and vegetable proteins are 
not alike in proportion even if they are in kind, and V. C. 
Vaughan says that "a man with a perfect digestion absorbs the 
nitrogen of his food as amino acids. " 

It would lead too far afield to discuss or name the various 
kinds of proteins, except that it is of interest to clinicians to 
note that those containing nucleic acid (nucleoproteins) are 
the ones that yield the purins (xanthin, etc.), and phosphoric 
acid. It is this group of proteins, nucleoproteins, that should 
be removed from the diet in conditions of uric acid retention. 
These nucleoproteins, cellular proteins, represent the cell nuclei 
of tissues. Hence the protein foods that contain a large 
amount of small cells (the glandular organs) also contain a 
large amount of nucleoprotein. 

It should be noted that students of nutrition find no great 
difference except in the fat content, and therefore in the speed 
and ease of digestion, between red meat and white meat, or 
between meat, fish and chicken. Veal is laxative to many 
people. One gram of protein has an energy value of four 
calories, and meat causes heat to be produced by the body, 
probably because it awakens a large amount of glandular and 
chemical activities. Hence cold, flabby people should eat 
more meat. 

A much used name for protein foods is " nitrogenous foods," 
because they contain nitrogen. Most of these proteins are very 
complex bodies, comprising many amino acids, and each protein 



580 THE PRINCIPLES OF THERAPEUTICS 

must be digested into its component parts (" bricks" as Lafay- 
ette B. Mendel terms them) before it can be absorbed and 
circulate in the blood. About eighteen amino acids have been 
recognized. Each part of the body will select from the blood 
and lymph the nutritive fragments that it needs for its activity, 
growth, reconstruction and up-keep. 

Most proteins are split up into amino acids in the intestines, 
and absorbed as such. The most important sources of proteins 
are meat, fish, poultry, eggs, milk, cheese, wheat, beans, peas, 
and oats. Meat, fish, eggs, and milk contain the protein 
elements necessary for body growth and up-keep. Casein is 
the principal protein in milk. A large part of the protein of 
wheat, gliadin, is not a very valuable protein food. Gelatin 
is a protein, and nuts furnish a valuable source of protein for 
food. Cooked beef contains from 22 to 30 per cent, or more of 
protein; lamb about 20 per cent; and mutton more than lamb; 
turkey about 28 per cent.; chicken about 18 per cent.; fish from 
21 to 26 per cent.; oysters and clams about 6 per cent.; boiled 
eggs about 13 per cent. ; cheese about 26 per cent. ; peas about 
25 per cent. ; peanuts about 26 per cent.; pine nuts about 34 per 
cent.; almonds about 21 per cent.; English walnuts about 16 per 
cent.; Brazil nuts about 17 per cent. Fish is a valuable protein 
food, and the oily varieties represent high caloric value. 

The approximate time, in a healthy individual that it takes 
to digest proteins is as follows: beef requires from 3 to 4 hours; 
mutton about 3 hours; lamb about 2% hours; boiled fish i}i to 
2 J12 hours; boiled ham 2 to 3 hours; raw oysters 2 hours; sweet- 
breads 2 hours; poultry 2 3^ to 4 hours; goose 4 to 5 hours; 
milk 2 hours; hard boiled eggs 3 to 3^ hours; cheese 3 to 4 
hours. However, the stomach digestion of meat varies in its 
duration in different individuals, there being two types, the 
slow and the fast, and it does not make much difference as to 
the manner of cooking the meat. If the digestion is normal, 
the stomach should be empty in 3 to 4 hours. 

Briefly, the digestion of proteins means a change largely to 
proteoses and peptones in the stomach, and a further splitting 
in the intestine to amino acids. Underhill 1 says that such 

1 The Physiology of the Amino Acids, F. P. Underhill. 



PROTEINS 581 

amino acids as are not or cannot be absorbed may be acted 
upon by putrefactive bacteria, and the amino acids especially 
susceptible to such action are tyrosine and tryptophan. Many 
compounds including phenol may be formed from tyrosine. 
Besides indole and skatole, the more commonly recognized 
members of the putrefactive group, Underhill describes another 
type of putrefactive products, the amines. Tyramine is 
formed from tyrosine and resembles epinephrine chemically 
and pharmacologically. Tyramine occurs in ergot and causes 
contraction of the uterus. While tyramine is produced in the 
intestine, Underhill says it may also be ingested with such 
foods as Camenbert, Roquefort and other cheeses. 

The production of this blood-pressure-raising substance in the 
intestine and the ingestion of food containing it should appar- 
ently be prevented in high blood-pressure cases. Normally 
there is about 1 part of epinephrine in 100,000,000 parts of 
blood. 

Many other amines, more or less poisonous to the system if 
largely absorbed, are produced in the intestine by the activity of 
putrefactive bacteria; hence the necessity of preventing putre- 
faction by diet and catharsis. The amount of putrefaction in 
the intestine, namely, the amount of indole, skatole, etc., is 
indicated by the amount of indican and ethereal sulphates in 
the urine. 

The stomach absorbs but little protein digested products, but 
the intestine absorbs not only the amino acids, but perhaps 
proteoses and peptone, although Underhill states that the 
proteoses and peptones may disappear from the intestines^ 
because they break up into amino acids and are absorbed only 
as the latter. 

Tissue breakdown, or tissue waste, perhaps means again 
destructive metabolism to amino acids, to again be built up 
into products for excretion as urea, creatin, creatinin, etc. The 
amount of urea excreted a day is about 30 grams, and it is now 
known that it is not all produced in the liver as once thought, 
but is produced by all the tissues of the body. If there is 
plenty of water in the tissues and the kidneys are healthy, urea 
is rapidly excreted in the urine. If the kidneys are diseased 



582 THE PRINCIPLES OF THERAPEUTICS 

and cannot excrete the urea, it stores in the blood and tissues 
though some may be excreted in the bile. Hence the advisa- 
bility of catharsis in such conditions. Urea is not a dangerous 
toxin, and "uremia" is misnamed. Other substances retained 
with urea are more toxic. 

The skin cannot excrete much nitrogen, hence not much urea 
even in kidney defect. Normally the skin excretes less than 1 
gram of nitrogen per day. 

Underhill states that "an amino-acid may be regarded as an 
organic acid in which one hydrogen is replaced by the amino 
group (N H 2 )." An amino acid leaves the body as urea, 
carbon dioxide and water. If this normal change does hot 
occur, other undesirable products may occur, according to 
Underhill, as for instance, leucine may become keytone acid, 
and keytone acid a fatty acid, and this by another chemical 
change may become acetone and acetic acid, and the factors of 
acidosis are in evidence. In a diabetic metabolism leucine 
may change to beta-oxybutyric acid instead of to acetone. 

Under certain conditions, notably in diabetics on a starch- 
and sugar-free diet, protein may furnish large amounts of sugar. 
In acidosis creatin may appear in the urine without carbo- 
hydrate starvation, but alkalies given freely and early may 
prevent creatinuria. 

There is, according to Underhill, no evidence to show that any 
aminoacid is formed in the body by synthesis except glycocoll. 

Urine acidity is increased by whole wheat bread and by all 
cereals, and decreased by such fruits as oranges, apples, canta- 
loupe, and bananas. 

VIT AMINES 

To Doctor Thomas B. Osborne, Professor Lafayette B. 
Mendel, McCollum and others must be given the credit of 
demonstrating by long experimentation on growing animals the 
presence in some foods and the absence in others of certain 
elements with which animals grow and thrive and without which 
they fail to grow and lose weight. These essential substances 
are termed vitamines, some of which are water-soluble and 
some fat-soluble. 



VITAMINES 583 

The fat-soluble vitamines are necessary for the growth of 
animals and for their proper nutrition. These vitamines occur 
in butter (milk fat), egg yolk, cod b'ver oil, and in more or less 
of the yellow fats of animal origin, but are deficient in the fat 
of the pig, according to McClendon. Fat-soluble vitamines 
are also present in carrots, potatoes, and bananas. Oleo- 
margerine when made of meat fats contains some vitamines 
satisfactory for growth, but margerines made from nut oils are 
deficient in vitamines, although there may be a little in peanut 
oils and peanut butter. Animal oils may lose their vitamines 
if they are subjected to hardening by chemical processes, but 
Osborne and Mendel found that the vitamine of butter is not 
destroyed by a year of cold storage. 

Osborne and Mendel found that phosphates deposit in the 
urine of animals if they are not fed a sufficient amount of fat- 
soluble vitamines. 

It has long been clinically known that the administration of 
cod liver oil and phosphates was of benefit in rickets and in 
cachectic children, and seemed at times to prevent rickets, and, 
lately, Hess has demonstrated that cod liver oil is of great bene- 
fit in this disease. After long feeding tests he does not believe 
that privation of fat-soluble vitamines is a cause of this disease. 
However, some vitamine in the cod liver oil may be of active 
benefit. It would seem that, when a child's digestion is dis- 
turbed by an ordinary amount of fat and yet less fat allows 
emaciation, cod liver oil in small amounts will solve the nutrition 
problem. 

The water-soluble vitamines are necessary for appetite and 
nutrition, and in their absence physiologic disturbances occur. 
Water-soluble vitamines are found to a small extent in ordinary 
beef, but more especially in the glandular tissues, such as the 
liver, kidneys and pancreas. Yellow corn meal contains a water- 
soluble vitamine, and Osborne and Mendel have shown that the 
tomato is rich in water-soluble antineuritic vitamines and in 
fat-soluble vitamines (fat-soluble A) which are characteristic 
of milk fat and egg fat. Tomatoes have also been shown to 
have antiscorbutic properties, even when dried or canned. 

The antiscorbutic vitamines are water-soluble, and they are 



584 THE PRINCIPLES OF THERAPEUTICS 

found in oranges, lemons, tomatoes, and in some other foods. 
Feeding these foods will prevent and cure scurvy. The anti- 
scorbutic dose of orange juice is about a tablespoonful, but 
larger doses may at times increase the child's weight. Osborne 
and Mendel have shown that orange juice also has a water-solu- 
ble B, the antineuritic vitamine, as well as its antiscorbutic 
\d taurine. They have also found this vitamine in the inner peel. 
Antiscorbutic vitamines are also more or less present in fresh 
vegetables, as cabbages, spinach, turnips, and the acid fruits, 
and generally they are not destroyed by cooking. 

The antineuritic vitamines are also water-soluble. They are 
found in yeast and in the outer shell of many cereal foods, and, 
as above stated, in orange juice. A proper amount of these 
foods will prevent the occurrence of beriberi. A diet more or 
less limited to polished rice has been the most frequent cause 
of this disease. 

It will probably be demonstrated that pellagra is due to pri- 
vation of vitamines. In the absence of these there is a tendency 
for the animal, and probably for the human, to acquire infec- 
tions, especially of the mucous membranes of the alimentary 
tract, and such infection adds its symptoms to that of the orig- 
inal pathologic condition. 

Normally fresh, unheated milk contains, according to Osborne 
and Mendel, all the vitamines necessary for growth and health. 
Some of these vitamines are destroyed by pasteurization, and 
perhaps all are destroyed by more rigorous modes of sterilization. 

The mother's mammary glands during lactation apparently 
have the ability to select vitamines from her blood, thus render- 
ing her milk a most perfect food for the growth of her child. 
The mammary glands probably do not synthetize these vita- 
mines, hence if the mother's food is inadequate for her own 
health and for the proper vitaminizing of her milk, the baby will 
suffer. Also, her milk may contain a sufficient amount of one 
or more vitamines, but be so deficient in another vitamine that 
the child will suffer accordingly. A lack of vitamines in the 
food may not only cause the mother to lose her appetite, but 
also her child may refuse to nurse. 

Osborne and Mendel have found that cow's milk is not very 



VITAMINES 585 

rich in water-soluble vitamines, hence if for any reason the 
child takes an insufficient amount, or the milk is too diluted, 
symptoms of scurvy may develop. Also in such artificially fed 
infants some fruit juices, generally best as orange juice, should 
be added to the diet. 

Osborne and Mendel and others have shown that milk is 
comparatively low in antineuritic vitamines. Hence if diluted, 
or not enough is taken, the child receives an insufficient amount 
of this vitamine. To meet this need, Daniels, Byfield and 
others 1 suggest a vegetable soup, especially prepared, to use as a 
diluent for milk rather than water. They found when this was 
added in sufficient amount to the child 's nutriment that normal 
growth was caused. Their feeding experiments seem to prove 
that diluted cow's milk is insufficient in antineuritic vitamines, 
while mother's undiluted milk is generally sufficient in this 
needed element of nutrition. 

An insufficient amount of vitamines in the milk may lead to 
structural trouble in the child later, such as rickets. Also, an 
insufficient amount of vitamines lowers normal immunity to 
infection, as evidenced for instance, by inflammation of the eyes 
occurring after they have become abnormal from privation of 
fat-soluble vitamines. 

Most so-called infant foods do not contain much vitamines, 
as these occur in the outer husk or shell of cereals and are 
largely lost by milling; hence the higher refined the flour, the less 
vitamines it contains. Too finely milled corn and barley have 
also lost their vitamines. Barley contains a water-soluble vita- 
mine, and Osborne and Mendel have found that the soy bean 
contains both water-soluble and fat-soluble vitamines. Besides 
being of high protein value, the soy bean also contains a large 
amount of oil, hence this legume is a very valuable food. 

Experiments have been made to determine whether or not 
dried vegetables and dried fruits have lost their vitamine con- 
tent, and it seems probable that at least they are not wholly 
lost by such treatment, but prolonged cooking of fresh, clean 
vegetables is not advisable, if the vitamines are not to be dim- 
inished in amount. However, canned foods, if there is any 

1 Amer. Journ. Dis. of Child., Dec, 1919, p. 546. 



586 THE PRINCIPLES OF THERAPEUTICS 

suspicion of the presence of the B. botulinus must be boiled 
before serving. 

Osborne and Mendel 1 have found that when rats are fed yeast 
as the only source of protein and water-soluble B vitamines, the 
males are generally sterile. This is perhaps due to the effect 
of the insufficient diet on the endocrine glands. The part that 
the endocrine glands play in the disturbances of nutrition caused 
by privation of vitamines has not, as yet, been studied. 

PURINS 

The purin bases are xanthin, hypoxanthin, guanin, and ada- 
nin. These substances and uric acid are termed purin bodies. 
A nucleoprotein food yields nucleinic acid which furnishes purin 
bases and by oxidation forms uric acid. Uric acid may be pro- 
duced by the breaking down and oxidation of the cells of the 
body (endogenous uric acid) and by the breaking down and 
oxidation of the nucleoproteins ingested as foods (exogenous 
uric acid). 

The amount of uric acid excreted in the urine represents 
largely the amount of purins ingested plus the amount of body 
nuclein breakdown. The amount of uric acid normally ex- 
creted by an adult on a mixed diet is from 0.30 to 0.50 Gm. 
daily, although he may excrete 0.30 Gm. on a purin-free diet 
from his own nucleolar breakdown. 

Some of the nucleoprotein or purin bases ingested are retain- 
ed in the body or used for the building of cells. On a mixed 
diet about 2 per cent, of the nitrogen ingested is excreted as uric 
acid. At times, however, large amounts of uric acid are ex- 
creted, showing a sudden breakdown or destruction of body 
purins, namely, a nucleolar (cellular) loss as often occurs in 
leukemia. 

A purin-free diet means that a patient must not eat meat, 
fowl or fish in any form, except perhaps such shell fish as oysters 
and clams. Also he must not take tea or coffee, although coffee 
deprived of its caffeine is not objectionable. The glandular 
meats contain the most purin. These are the sweetbreads, 
liver, kidney, and roe of fish. Peas, beans and asparagus con- 

1 Journ. of Biolog. Chem., 38, 1919, p. 223. 



MILK 587 

tain purin in small amounts. The intestinal bacteria may 
destroy a certain amount of the purins of the food. 

MILK 

Milk deserves separate discussion, as it contains all the 
elements necessary to preserve life, especially for young animals. 
Cow's milk contains a little over 3 per cent, of protein, about 
5 per cent, of carbohydrates, about 4 per cent, of fat, and some- 
thing less than 1 per cent, of mineral matter, while about 87 per 
cent, of it is water. The protein is mostly (80 per cent.) in the 
form of casein, which is the protein of cheese and which contains 
a little phosphorus and sulphur. Another important protein is 
the lactalbumen, which is the principal protein of the whey. 
Though the casein is the more easily digested of these two 
proteins, the lactalbumen, which is lost in the making of cheese, 
has a distinct nutritive value. The butter fat of milk contains 
an important vitamine. The lactose, the milk sugar, besides 
being a valuable carbohydrate, tends to produce lactic acid in 
the intestine and to greatly increase the B. acidophilus, which 
germ checks putrefaction in the intestine. Milk also contains a 
large amount of calcium. 

Mother's milk contains all the elements necessary, including 
salts, for the growth and health of the child, but the constitu- 
ency of human milk varies greatly at different times, especially 
in its nitrogen content. Human milk contains a little more 
fat than cow's milk and considerable less than goat's milk, 
while both cow's and goat's milk contain more casein than 
human milk. Human milk contains from 1 to ij^ per cent, 
more milk sugar than that of the cow or goat. Cow's milk, 
then, as a food for infants contains more casein than is needed, 
less sugar than is needed, and, even when diluted, more salts 
than may be well tolerated by. the infant, although if much 
diluted it contains an insufficient amount of iron. Hence when 
an infant receives a greatly modified cow's milk as a food, 
he may become anemic. Also it is a mistake to believe that 
the infant cannot soon digest small amounts of carbohydrates. 

Milk contains ferments which are more or less destroyed by 
heat, and although boiled milk is safe as far as being a germ 



588 THE PRINCIPLES OF THERAPEUTICS 

carrier, it loses some of its vitamines, and, as Hess has shown, 
the antiscorbutic vitamine is destroyed by boiling, and scurvy 
may occur in a child fed only on boiled milk. Boiled milk is 
also constipating. 

To sterilize milk of all bacteria and most bacterial spores 
it must be subjected to a temperature of 212 F. for fifteen or 
twenty minutes. Some spores may even survive this tempera- 
ture for this length of time. The health bulletin for April, 
1920, issued by the Connecticut State Board of Health defines 
pasteurization as a process by which milk is rapidly heated to 
a temperature of not less than 142 F. and not more than 
145 F., which temperature should be maintained between these 
figures for not less than thirty minutes, and the milk must 
then be immediately cooled to a temperature of not more than 
50 F. Pasteurization will inhibit germ growth, but does not 
necessarily destroy bacteria. 

"Certified milk" should not contain more than 10,000 
bacteria to the mil (c.c.) but like all other bacteriologic tests, 
variations in the report of bacterial content of a given milk 
occur when samples are sent to different laboratories, and 
a milk may be thoroughly good that has a much larger bacterial 
count. Also, it should be noted that milk may carry an infec- 
tion even if the bacterial count is low. Therefore of very 
great importance are the conditions under which the milk is 
produced, handled, and marketed. 

Milk must not contain a preservative, not even sodium 
borate, and it must contain a certain amount of cream, and must 
not be diluted with water, to be marketable, according to the 
laws of most boards of health. The cow barns, the condition 
of the cows, and the cooling and bottling of the milk are all 
subject to sanitary laws. 

• If a patient dislikes milk, its character may be changed by 
serving it hot, or diluted with plain water, barley water, an 
alkaline charged water, as vichy, or with a water charged with 
carbon dioxide gas. If salt is added to the milk, its character is 
changed. Junket may be made, or if desired the milk may be 
peptonized. 

Popular drinks to-day are skimmed milk and buttermilk. 



MILK 589 

Buttermilk is the milk that is left after the fats have been 
removed in the process of making butter, while skimmed milk is 
the residue which is left after removing the cream. Skimmed 
milk has good protein value. Buttermilk tastes a little acid, 
and is generally made to-day for beverage purposes by adding 
lactic acid bacilli; the most used germs for this object are the 
Bulgarian bacilli. 

Various names are given to soured and fermented milks; 
the pleasantest of these milks are those that are sparkling and 
effervescent. A popular form in this country is termed koumys 
(also spelled kumiss), which is the name applied to fermented 
mare's milk in Asia Minor. It may be made at home by adding 
to a pint of milk two teaspoonfuls of sugar and about % of an 
ordinary yeast cake. This is put in a bottle and corked tightly, 
and should stand about ten hours in a place where the tempera- 
ture is about 99 to ioo° F. It should then be placed in a 
refrigerator, to be drunk as needed. 

Other names for fermented milk are yoghurt, which is the 
Bulgarian soured milk, kefir which is the name given to fer- 
mented cow 's milk in the Caucasus Mountains, and matzoon is 
the name for the milk fermented in Syria. All of these fer- 
mented milks are very nutritious; but, like taking the Bulgarian 
bacilli too long for intestinal fermentation, they are likely to 
cause an increased acidity or at least a lessened alkalinity of 
body tissues, and should not be used too long without inter- 
mission. In other words, the lactic acid bacilli fad has been 
overdone. 

Also, there has been too much artificial alkalinization of 
infant foods. These alkalies can cause a loss of vitamines and re- 
duce the antiscorbutic powers of milk, according to Alfred F. Hess, 
of New York. When it is advisable to add an artificial food to 
the milk for infants, the value of barley water and oatmeal 
gruel should be considered. Barley water is more or less con- 
stipating; oatmeal gruel or water, more or less laxative. Oat- 
meal also carries with it a little iron, and milk contains but a 
minute quantity of iron. 

Top milk as it is called, contains nearly twice as much fat 
as bottom milk, while skimmed milk contains only about one- 



590 THE PRINCIPLES OF THERAPEUTICS 

third of the fat that bottom milk contains. Whey of milk 
contains only a small amount of fat. 

CHEESE 

Cheese is a most valuable nutriment and is generally not 
difficult of digestion, the soft cheeses being more digestible than 
the hard cheeses; but if a hard cheese is completely masti- 
cated before swallowing, it also, will be easily digested. It 
should be remembered that not only milk, but cheese and butter 
made from milk may contain pathogenic bacteria. Cheese is 
nearly two-thirds of its bulk protein and fat, (from 25 to 35 per 
cent, protein) and thus is not only a builder of tissue and a sub- 
stitute for meat, but also furnishes many calories of energy. 
Although Swiss cheese is made from goat 's milk, it is being well 
made in this country from cow 's milk. It is no longer necessary 
to depend upon imports for good cheeses; all varieties are now 
well made in America. Cheese should be more depended upon 
in this country as a valuable nutriment than has previously 

been the case. 

EGGS 

Eggs represent one of the most concentrated and satisfactory 
of foods. The nutritional value of an ordinary egg equals 
about the value of 1 50 grams of milk or 50 grams of meat, and 
furnishes about 80 calories. The food value of a raw egg is 
mostly only that of its yolk; the value of raw egg albumen is 
questionable. Raw egg albumen remains only a short time in 
the stomach, and passes rapidly down the intestines, hence 
feeding egg albumen during illness of any kind is a method of 
mythical value only, and such feeding should cease. It has 
lately been shown by Hawk and others 1 that hard-boiled eggs, 
in spite of the antipathy against them, require but a few 
minutes longer for digestion than the time required for soft- 
boiled eggs. Scrambled eggs require a little longer time ; fried 
eggs are digested as readily as soft-boiled eggs. Omelets take 
a little longer time for digestion. Poached eggs and shirred 
eggs are digested as readily as soft-boiled eggs. 

Rettger has shown that ovarian infection of hens may occur 

x Amer. Journ. of Physiol., July i, 191 9, p. 254. 



CARBOHYDRATES 59 1 

and the yolk of the eggs they lay may carry the germs, the white 
of the egg rarely. Although it has not been clinically noted 
it is possible that infected eggs eaten raw may cause gastroin- 
testinal disturbances. If the shells of eggs remain dry the 
contents of the egg are not likely to become contaminated, but 
if the shells are moist and soiled, decomposition is promoted. 

NUTS 

Nuts, especially peanuts and almonds are valuable foods, 
containing protein, carbohydrate, and oil. Peanut butter is a 
valuable food for children. 

CARBOHYDRATES 

Carbohydrate foods contain starch and sugar which are 
composed of carbon, oxygen and hydrogen. As previously 
stated, the measure of energy of any food is the calorie, and the 
adult requires, on the average, about three thousand calories 
per day. For his health and welfare these calories must be 
acquired from a well balanced diet. He will not thrive if the 
food is all of one type, even if he does acquire the necessary 
number of calories. The protein of the diet may well furnish 
from 400 to 500 calories per day; the rest of the calories must 
be acquired from starches, sugars and fats. 

The more fat a pound of meat contains, the greater the 
amount of calories. It may roughly be estimated that one 
pound of meat will furnish about i ,000 calories, very lean meat 
less, .very fat meat much more. Fish and poultry furnish 
somewhat less than a thousand calories per pound. The 
following table is approximately correct: 

An egg equals about 80 calories. 

A pint of milk about 325 calories. 

A pound of cheese about 2,000 calories. 

A pound of wheat bread about 1,100 calories. 

A pound of baked beans about 600 calories. 

A pound of potatoes about 450 calories. 

A pound of rice about 500 calories. 

A pound of bananas about 450 calories. 

A pound of oranges about 250 calories. 



59 2 THE PRINCIPLES OF THERAPEUTICS 

A pound of nuts from 2,500 to 3,200 calories, peanuts furnish- 
ing the least amount and English walnuts the most. 

More exact and more complete tables of the caloric value of 
foods will be found in books entirely devoted to the subject of 
foods and diets. It should be remembered, however, that the 
more fat and oil a food contains, the greater the amount of 
calories it represents. One gram of albumin represents four 
calories, one gram of carbohydrate four calories, one gram of 
fat nine calories, and one gram of alcohol seven calories. 

Ordinary yeast-raised (leavened) bread contains about 53 per 
cent, of carbohydrate, about 1 per cent, of fat, and about 9 per 
cent, of protein. The ready-to-eat cereal foods, according to 
Street 1 are all made from whole wheat, corn, rice, and sometimes 
from barley and rye. Oats have a large amount of protein and 
fat value, while wheat, rye and barley have a high protein 
content but less fat. Corn has a high fat content, while rice 
is low in protein. Sugar or syrup is added to many of the 
breakfast foods. The less highly milled and the less finely 
prepared the breakfast food, the more laxative the properties. 
It may ordinarily be estimated, says Street, that one ounce of 
any of the commonly used breakfast foods yields about 100 
calories, but these foods have lost some of their vitamines in 
their preparation, and though of good caloric value are of 
poor protein value. The wheat foods are the most readily 
digested, the oat foods next, and the corn foods are the most 
difficult of digestion. 

Rice is a very valuable food, of high caloric value, and is 
easily and quickly digested. It should be more used, especially 
as a breakfast food and as a substitute for potatoes. 

The flour paste foods, as macaroni, vermicelli and spaghetti, 
are valuable foods, both from a protein and from a caloric 
standpoint. Whole wheat is 71 per cent, carbohydrate, 13 per 
cent, protein, 12 per cent, water, and 12 per cent, mineral salts. 
These mineral salts are principally potassium, phosphorus, and 
magnesium, with a small amount of calcium, sodium and iron. 

The potato is like a cereal grain, and baked potatoes are 

1 Connecticut Agricultural Reports, Bulletin 197. 



CARBOHYDRATES 593 

more easily digested than boiled potatoes. When potatoes are 
too early harvested and sprout, unless these sprouts are com- 
pletely removed before cooking and eating, poisoning may be 
caused by the toxic glucoside, solanin, which the sprouts con- 
tain. The symptoms of such poisoning, which is rare, are 
abdominal pains, vomiting and diarrhea. 

The legumes, peas and beans, and similar protein vegetables 
contain about 25 per cent, of protein; the soy bean contains a 
high percentage of protein. 

Bananas offer a good food for children, but they must be 
thoroughly ripe, and may be eaten raw or baked. When 
green they are about 22 per cent, starch; when ripe they become 
sucrose, and finally invert sugar. One gram of the pulp equals 
about one calorie. 

Although young children require a large amount of starch and 
more or less sugar, sometimes they show an intolerance to 
them, as evidenced by indigestion. Recent studies on energy 
and metabolism and the caloric need of children from birth to 
puberty have been made in the Boston Nutritional Laboratory 
of the Carnegie Institute at Washington, and the results may 
be found in "The American Journal of the Diseases of Children" 
Oct., 1919, p. 229. 

Carotinemia is a term applied to abnormal pigmentation of 
the body which may occur from eating vegetables rich in 
carotin, which Hess and Meyers have shown occurs in carrots, 
spinach, egg yolk and oranges. Individuals who have eaten 
an unusual amount of these substances may have yellow 
pigmentation of the body and a highly colored urine. 

Hawk and others 1 have recently determined that raw 
vegetables, as celery, lettuce, tomatoes and cucumbers, leave 
the stomach rapidly, while the boiled vegetables are more 
completely disintegrated in the stomach, and that starchy 
vegetables, as potatoes, have considerable of their starch 
digested before leaving the stomach. 

Sugar. — The sugars belong to two groups; the monosaccharids 
comprise dextrose, levulose, and galactose, and the disaccharids 
comprise saccharose, maltose, and lactose. 

1 American Journal of Physiology, Mar. 1, 1920, p. 332. 



594 THE PRINCIPLES OF THERAPEUTICS 

Dextrose, glucose (grape sugar), is a normal constituent of 
some body tissues, and carbohydrates are probably largely 
absorbed as glucose. Saccharose (cane sugar) is the most 
important form in which sugar is taken as a food, except for 
young children. It is converted in the alimentary canal into 
glucose (dextrose) and fructose (levulose). Maltose is formed 
from starch by the saliva and pancreatic juice. Lactose (milk 
sugar) saccharose and maltose cannot be absorbed as such; 
they are inverted to monosaccharids in the alimentary tract. 
These are then stored in the liver and muscles as glycogen, 
so-called animal starch. About 150 Gm. of sugar a day will 
satisfy the body need . 

About 50 per cent, of the calories of breast milk is furnished 
by the milk sugar. There is no necessity for giving an infant 
any sugar other than lactose; but it should be remembered that 
the young child requires relatively more sugar than the adult. 
Maltose and lactose are often added to the milk of young 
children, as not only furnishing extra nutriment, but the 
maltose seems to increase the digestibility of the milk, and the 
lactose diminishes intestinal fermentation. Cane sugar often 
does not agree with the young child. At the same time it 
should be recognized that sugar is a stimulant and promoter of 
nutrition in young children, besides having caloric value. The 
susceptibility of young children to cane sugar varies, some 
tolerating considerable amounts, others being actually poisoned 
by it, as shown by vomiting, frequent colds, eczema, asthma, 
and other more or less anaphylactic disturbances. Most older 
children eat too much sugar, especially in the form of candy. 
The privation of the war has shown that sugar, as such, is 
not essential to health, in fact the enormous amount of candy 
manufactured, and the inordinate use of sugar in soda and 
other "soft" drinks represent a mistake of civilization. The 
gastric digestion is generally delayed by much candy and by 
sweetened drinks. 

The sweet potato contains more starch and much more sugar 
than does the Irish potato. The sugar is identical with cane 
sugar. Molasses is a side product in the process of extracting, 
sugar from the sugar cane. The glucose obtainable is mostly 



ALCOHOL 595 

made from starch by hydrolysis; lactose is made from milk; and 
levulose from fruit, i.e., fruit sugar is levulose. 

Barbour (Laboratory of Pharmacology, Yale University) has 
recently found that dextrose given by the mouth seems to 
exhibit an antipyretic action and to increase heat elimination. 
This suggests the inquiry as to whether carbohydrate meta- 
bolism plays an important role in the action of antipyretic 
substances. 

Saccharin. — Saccharin is a coal-tar derivative of no food 
value. It is a sweetener, but if long used, even in small amounts, 
often interferes with digestion, although some patients have 
taken this substance for years, in considerable amounts, with- 
out apparent harm. However, it seems inexcusable to use 
saccharin promiscuously as a sweetener for foods, and it should 
be prohibited from use in the canning industry. 

Saccharin is eliminated in the urine unchanged, and has been 
thought to have some antiseptic properties in inflammation of 
the pelvis of the kidney. 

ALCOHOL 

Alcohol, though in disgrace, may, under proper conditions and 
in certain diseases, be used, not only as a drug, but as a food. 
Its food value is not unlike a sugar. It is largely absorbed 
from the stomach, and is rapidly burned in the body, even 
beginning to lose its identity in ten minutes or less after its 
ingestion. Alcohol will prevent or modify acidosis, and in 
starvation, or when other foods cannot be taken, it will preserve 
life in emergencies and prolong life in serious conditions. 

In this age of prohibition and the consequent increased 
ingestion of so-called soft drinks and sugars, it may be well to 
note that even the root beer of would-be total abstainers, 
if made with yeast, sugar, water and the root extracts, corked 
and allowed to stand, will often yield about i per cent, 
of alcohol in ten days, i.e., double the allowed beer brewing 
strength of Y% per cent. 

Just for historical interest the once alcohol content of a 
few old time preparations may be noted. The average alcohol 
content of: 



596 THE PRINCIPLES OF THERAPEUTICS 

Whiskey is 48 per cent. 

Brandy, 50 per cent. 

Gin, from 20 to 35 per cent. 

Rum, 60 per cent. 

Sherry, 18 per cent. 

Port, 18 per cent. 

Sauterne, 14 per cent. 

Claret, 10 per cent. 

Champagne, 10 per cent. 

Ale, 6 per cent. 

Beer, 4 per cent. 

All malt beers are rich in carbohydrates. 

FATS 

Neutral fats represent a considerable part of body tissues, 
and may become so increased in amount as to impair the ac- 
tivity of the individual and to interfere with important physio- 
logic processes. 

Fats are emulsified in the intestine, and are more or less de- 
composed into fatty acids and glycerin. The fatty acid unites 
with alkali in the intestine to form an oleate, stearate, or pal- 
mitate, according to the kind of fat ingested. The fatty acids 
combined with the alkaline bases sodium, potassium and cal- 
cium, occur only in the intestines. Ultimately fat is burned 
(oxidized), producing energy, to be later eliminated as water and 
carbon dioxide. 

The adult ordinarily takes about 60 Gm. (2 ounces) of fat a 
day. The Chinese, Japanese, East Indians and vegetarians eat 
little or no fat as such, but get their fat nutriment from vege- 
tables and cereals, hence animal fats may not be essential. 

In certain disturbances of nutrition, especially in poisoning 
by certain drugs, as phosphorus, arsenic, chloroform, alcohol, 
etc., fat is deposited in large amounts in the intercellular tissue, 
notably in the liver. 

Those who eat considerable amounts of fat are said not to 
as readily acquire tuberculosis, and it seems to be a fact that 
when the tuberculous patient begins to add fat, his condition 



fats 597 

generally begins to improve. Consequently, it has long been a 
part of the treatment of tuberculosis to push fats in the diet. 
Such treatment, however, has been much overdone, to the di- 
gestive disturbance of the patient. Also, a tuberculous patient 
may gain weight and still the disease may progress; and an over- 
weight patient may acquire tuberculosis. 

If normal bile, and a normal amount of it, does not reach the 
intestine, fat is not well digested and absorbed, hence in liver 
disturbances and gall-duct obstruction the animal fat intake 
should be restricted. 

With carbohydrate-free diets, as in diabetes, fat must not be 
pushed, lest acidosis be caused. The following fat content of 
foods may be noted: 

Butter is 90 per cent. fat. 
Cream about 27 per cent. fat. 
Olive oil 70 per cent. fat. 
Cocoanuts 57 per cent. fat. 
Pecans 71 per cent. fat. 
Walnuts 64 per cent. fat. 
Peanuts 49 per cent. fat. 
Oatmeal about 5 per cent. fat. 
Chocolate and cocoa are rich in fats. 

Since olive oil costs so much, it is well to note that the best 
quality of cottonseed oil has an equal food value. 

Glycerin is a product of fat decomposition in the intestine. 

Lipoids. — Lipoids are now more frequently termed phospha- 
tids or phospholipins. The phosphorus-bearing lipoids seem to 
be present in all living cells, and are especially important in 
nervous tissues. They seem necessary for fat metabolism, and 
also seem to be concerned not only in the coagulation of the 
blood, but in the destruction of blood (hemolysis). It has 
lately been found that these phosphatids are not of multiple 
structure, but are more or less constantly composed of lecithin 
and kephalin in varying proportions. 

Cholesterol (cholesterin) an alcohol, is a lipoidal compound. 
It occurs free, and in combination with fatty acids as cholesteryl 
oleate and cholesteryl palmitate. Although cholesterol was 



598 THE PRINCIPLES OF THERAPEUTICS 

thought to be a waste product of nervous tissue, it is now thought 
that it is probably not formed in the human body. Cholesterol, 
though occurring in other tissues of the body, notably the brain, 
is found in the bile as a normal ingredient. Under certain con- 
ditions it is deposited with bile salts as calculi in the gall-bladder 
or bile ducts. 

Phospholipins are chemically phosphoric acid in combination 
with a neutral fat and a nitrogenous base cholin, and lecithin is 
a phospholipin. Macleod says that lecithin is widely distrib- 
uted in the animal body, is present in the blood and bile, is an 
extremely important constituent of all cells, and "seems to be 
the intermediate stage in the utilization of neutral fats by pro- 
toplasm." He states that "its phosphorus probably serves as 
a source of this element for the construction of nucleic acid. In 
nervous tissues it is often associated with carbohydrate mole- 
cules (galactose), forming the substance known as cerebrin." 

The lecithin of the central nervous system will absorb an 
anesthetic, as will other lipoids. When it breaks up into its 
fatty acid and the nitrogenous body, cholin, the latter, though 
non-toxic, may be converted into neurin, which is poisonous. 

Lecithin is generally obtained as a combination of kephalin 
and true lecithin, and many preparations used for medicinal 
purposes contain glycerin. Preparations of lecithin have no 
advantage over egg-yolk, which is rich in lecithin. While ani- 
mals fed on lecithin seem to gain weight over control animals, 
the ingestion of considerable amounts of it as food or medicine 
may be objectionable, as there is a possibility of large amounts 
of cholin becoming changed in the intestine into neurin, which 
is toxic. Neurin acts as a paralyzant of the nervous system and 
is a depressant to the circulation. When lecithin is fed the 
urea is increased and the output of uric acid may be diminished. 
Consequently, it would seem contraindicated in gouty condi- 
tions. It has been used as a stimulant to tissue building in 
debility, but as above stated, if extra lecithin is desired, egg- 
yolk should be the form in which it is administered. 

Glycerophosphates are derived from lecithin, and probably 
have no therapeutic advantage over inorganic phosphates. 
They split up in the intestine and liberate inorganic phosphates, 



salts 599 

and during their administration uric acid is often diminished, 
perhaps because more nitrogen goes into urea formation. 

The most important use of glycerophosphates is in conditions 
of debility, and especially of nervous irritability. There seems 
to be no special advantage of one glycerophosphate over another, 
therefore, theoretically, the calcium salt (calcium glycero- 
phosphate) should be the preparation of choice, if a glycero- 
phosphate is desired. Calcium is certainly more or less of a 
nervous sedative, and the glycerophosphate form is apparently 
a good salt in which to administer it. 

SALTS 

Sodium Chloride. — This is the most important salt as it 
enters into all tissues of the body, solid and fluid, except the 
enamel of the teeth, but the foods we eat contain very little, 
except some of the sea foods. Consequently, civilized man adds 
salt to his diet, in fact, to almost every form of food. Human 
blood contains about 0.5 per cent, of sodium chloride, and it is 
needed for the production of the hydrochloric acid of the gas- 
tric juice. 

The amount of salt taken daily by the average adult is about 
10 to 12 grams, about 95 per cent, of which is, in health, rapidly 
eliminated unchanged. Consequently, there is a large surplus 
of salt ingested, due to an acquired taste for it, as about 2 grams 
per day will satisfy the needs of the body. 

Large amounts of salt doubtless interfere with digestion, and 
cause unnecessary work of the eliminative organs, especially 
the kidneys. If there is renal or cardiac insufficiency, salt 
causes and promotes edema. On the other hand, wasting 
diseases may increase the elimination and loss of sodium chlo- 
ride from the tissues, and under these circumstances an extra 
amount should be ingested; in fact, a man accustomed to salt in 
his diet and suffering from a protracted illness should not be long 
deprived of sodium chloride. 

Calcium. — The next most important salts are the calcium 
salts, and there is more calcium in the body than any other 
inorganic element except water. It occurs in large amounts 
in the bones, teeth, muscles, and milk. The adult requires 1.5 



600 THE PRINCIPLES OF THERAPEUTICS 

grams of calcium a day, as not far from that amount is excreted 
daily. In tuberculosis there is an increased amount of calcium 
excreted, and in osteomalacia the loss is excessive. 

Calcium salts quiet nervous irritability and diminish hyper- 
activity of some glands, notably the thyroid. However, this 
therapeutic effect may be caused by the favorable action of 
calcium in parathyroid deficiency, these glands being more or 
less disturbed in thyroid disturbances. The parathyroid 
glands are largely concerned in calcium metabolism. The 
pregnant woman should receive an increased amount of 
calcium. 

Alkali added to the milk of infants does not cause storage of 
calcium, but the addition of malt extract without alkalies does 
cause some storage of calcium, perhaps one of the advantages of 
adding malt extract to an infant's milk. Excessive calcium 
intake (perhaps taken as cow's milk) may cause mal-nutrition, 
especially if not enough sodium or phosphorus is ingested to 
form soluble salts, and, therefore, an accumulation of calcium 
occurs. It is difficult to increase the calcium content of the 
blood and tissues if they are saturated, but easy to increase this 
content if they are calcium depleted. The administration of 
dilute hydrochloric acid increases calcium and magnesium out- 
put as well as potassium and sodium output, and acidosis in 
diabetics may increase the loss of calcium. It has been sug- 
gested that scurvy may be due in part to calcium disturbance. 

Milk is an important calcium food. There is considerable 
calcium in greens, and in the green parts of vegetables. There 
is very little calcium in tubers and roots, but it may be supplied 
by carrots. 

Iron. — This metal is a necessity for health, but is required in 
such a small daily amount that it is easily obtained from an 
ordinary mixed diet. Spinach contains more iron than most 
any other food. Meat in all forms contains iron; even flour, 
oatmeal, rice and yolk of egg contain a small amount of iron. 
Milk, most vegetables and some fruits contain a little iron, and 
most waters contain iron in varying amounts. The salts con- 
tained in vegetables are largely combinations of potassium and 
sodium. 



WATER 60 1 

About 0.10 Gm. of iron per day is more than enough for iron 
metabolism. When iron is given a patient, the dose is generally 
so large in twenty-four hours, that most of it is wasted, and such 
dosage causes constipation, and, in patients who have an idiosyn- 
crasy against it, headache and a feeling of fullness in the head. 
Therapeutically an inorganic iron is as valuable as an organic 
iron. 

Zinc. — Zinc, long ago discovered by Mendel to be contained in 

marine mollusks, has been more recently found to be universally 

present in the oysters of the Atlantic coast. Bickner 1 has 

found that zinc is a normal, if not a constant constituent of 

many foods, and cow's milk averages 0.0042 Gm. of metallic 

zinc per kilogram {2% pounds) of milk. Also he found human 

milk contained even more zinc than cow's, and that hen's eggs 

contained 0.001 Gm. of zinc per egg (in the yolk). Cereals may 

also contain zinc. 

WATER 

About 60 per cent, of the body weight is water, and we cannot 
live, or even function, without water, and if we do not daily 
ingest as much as is lost from the body, we lose weight. How- 
ever, great privation of water in the obese is not a safe method of 
reducing weight. 

A goodly amount of water drunk with meals makes digestion 
easier and tends to reduce intestinal putrefaction, perhaps by 
promoting normal passage of the food debris to its exit, which 
should normally take place in about twenty-four hours. A 
large amount of water is used over and over again in the diges- 
tive processes. It has been shown that water is really a gastric 
stimulant, and, whether taken with or without food, it causes 
the secretion of the acid gastric juice. If the stomach is empty, 
water taken will enter the duodenum on an average in fifteen 
minutes. 

The amount of water that should be taken per day varies 
with the amount lost to the body. The individual who retains 
his same weight for months and years under varying conditions 
of perspiration and loss of fluid must automatically drink the 
amount of water his system requires. On the other hand, some 

1 Journ. Biological Chemistry, June, 1919, p. 191. 



602 THE PRINCIPLES OF THERAPEUTICS 

individuals drink but little water, and others drink water con- 
stantly. The excretion of water by the first individual is 
much less than the excretion of water by the other individual. 

Diabetics with polyuria must not be deprived of water, and 
patients who have cholera or dysentery must have plenty of 
water, and those who have suffered hemorrhage must have an 
increased amount of water. On the other hand, anemic 
patients should not be allowed to drink as much water as they 
often desire. Fever patients must have plenty of water for 
various reasons, and it has lately been suggested that high 
fever in infections may be in part caused by an insufficient 
supply of water for evaporation, for increasing metabolism, 
and for kidney excretion. An infant often does not get enough 
water. 

Water carries into the body more or less salts and minerals, 
and waters that contain large amounts of such substances are 
termed mineral waters, which are described in Part VIII. A 
valuable potable water should not contain much mineral matter, 
but to be pleasant must contain oxygen. Boiled water has lost 
its life, its oxygen and air, but is as useful as far as body nutri- 
tion is concerned. Distilled water is of value as a solvent and 
tends to prevent precipitation of salts by its ability to take up 
salts; hence it should be the water of choice when there is 
a tendency to deposits in the bile or urine. 

FRUITS 

Fruits are very valuable additions to our daily food, although 
they are 80 to 90 per cent, water. They all contain sugar, 
organic fruit acids, and some mineral salts. The acidity of 
fruits is largely due to organic acids and to acid salts. Some of 
them contain benzoic acid, as plums and cranberries. The 
principal acids of fruits are citric and malic acids. Those 
containing citric acid are cantaloupe, cranberries, currants, 
pomegranate, red raspberries, and some pears. Those contain- 
ing malic acid are apples, cherries, gooseberries, persimmons, 
plums, quinces, watermelon, and some pears. These acids 
burn, for the most part, to alkalies in the body, and though 
grape fruit, lemons and oranges are very acid fruits, they also 



COFFEE AND TEA 603 

burn to alkali in the body. Vinegar contains about 5 per cent, 
of acetic acid. It is now often made artificially. Grapes 
contain acid potassium tartrate, cream of tartar. Salads are 
more easily digested with lemon juice dressings than with 
vinegar and oil dressings. 

Fruits vary greatly as to their digestibility; also the ability 
to digest a given fruit well is often individual, some persons can 
well digest a fruit that another person cannot take without 
distress and many symptoms of indigestion. The cooked fruits 
are more readily digested than fresh fruits. Most fruits are 
laxative; a few are constipating on account of the tannic acid 
that they contain. The most laxative fruits are those that 
contain small seeds. Apples and oranges are very laxative for 
some individuals, while it has lately been found that orange 
juice may be apparently constipating to some young children. 
Prunes are a very laxative fruit. 

Citrates are more easily metabolized in the body than tar- 
trates and oxalates, but while oxalic acid is recognized as a 
poison, and Underhill long ago showed that tartrates could 
injure the kidneys, even too much citric acid, as well as other 
fruit acids, can cause physiologic disturbances. 

COFFEE AND TEA 

Coffee, with its full quota of caffeine, and tea, with its 
full quota of theine (which is the same as caffeine) are the most 
stimulating of our daily foods and drinks. They are stimulant 
to the nervous system, to the heart, and more or less raise the 
blood-pressure. These facts should preclude the use of these 
beverages (unless the caffeine has been removed) by those who 
are nervous, irritable, and sleepless, and by those who have high 
blood-pressure or irritable hearts. Some individuals always, 
and most individuals from forty to forty-five and upwards, are 
so stimulated by these caffeine preparations, that if they take 
them at the evening meal they do not sleep well. As these 
individuals grow older and their tension relaxes, as it often does, 
they may again be able to take tea or coffee in the evening 
without loss of sleep. 

The very fact that these beverages are such nervous stimu- 



604 THE PRINCIPLES OF THERAPEUTICS 

lants should prohibit their use by children. By the same 
decision, coca-cola, which contains on an average from i to i 1 ^ 
grains of caffeine to the glass, should not be a beverage for a 
child. The coffee, tea, coca-cola, or other caffeine habit may 
be readily acquired by any one, and may do as much harm, in 
some cases, as alcohol and tobacco. 

Coffee contains an oil, caffeol, which is more or less of a 
gastric stimulant, and hence rather tends to hasten digestion. 
This caffeol is the substance that gives coffee its pleasant 
aroma. 

Tea contains tannic acid, and if too long brewed this acid 
becomes strongly in evidence. Tea is constipating, while 
coffee somewhat increases peristalsis, and may be mildly 
laxative. 

Mendel and Wardell 1 after studying the effect of the ingestion 
of coffee, tea and caffeine on the excretion of uric acid in man, 
came to the conclusion that a strong infusion of coffee, even on a 
purin-free diet, will cause an increase in the excretion of uric 
acid, and that a decaffeinated coffee does not cause this increase 
in the uric acid output. The effect of an infusion of tea is the 
same as that of coffee. They also found that the amount of 
excretion of uric acid depended on the amount of coffee or tea 
taken. 

Most of the coffee used in America to-day is Maracaibo coffee. 
There is very little Mocha, and only a small amount of Java 
(relatively to the number of drinkers of coffee) that reaches this 
country. Both tea and coffee, unless carefully supervised by 
officials, will often be found adulterated. 

It is obvious that the daily intake of coffee and tea by an 
individual who seeks advice from his physician should be 
investigated. Also there is a distinct "tea and coffee habit." 

Hawk and others 2 found that evacuation of the stomach is 
not delayed by tea or coffee in ordinary amount, neither by 
tea and coffee with cream, nor with sugar and cream. With 
sugar alone the evacuation of the stomach contents was a 
little delayed, and coffee with sugar alone delayed the develop- 
ment of gastric acidity. 

1 The Journal A. M. A., June 16, 191 7, p. 1805. 

2 Amer. Journ. of Physiol., May 1, 1920, p. 28. 



NUTRIENT ENEMATA 605 

The cocoa bean contains about 50 per cent, of fat, which is 
often utilized as cocoa butter. It also contains from 1 to 2 
per cent, of theobromine. The cocoa used for a beverage has 
its fat removed, hence though very nutritious, it is easy of 
digestion. Chocolate preparations have the fat retained, and 
are generally made by the addition of sugar to cocoa. Plain, 
bitter, or milk chocolate may be obtained. All of these 
preparations are very nutritious, but are not beverages or 
foods that should be taken by individuals who ought not to add 
weight. 

NUTRIENT ENEMATA 

The rectum and lower intestine can absorb but little food, 
with the exception of sugar, alcohol, water, and some salts. It 
is doubtful if eggs or milk, so many times used as nutrient injec- 
tions, are absorbed at all. Beef juices may be slightly absorbed, 
and beef peptones may be absorbed, but the best food that can 
be given by the rectum is a sugar, and glucose is the best sugar 
for this purpose. The injection should also contain some 
vitamine. 

The bowels should first be washed out with a quart or more 
of warm water, which may contain bicarbonate of sodium, an hour 
before the nutrient enema is given. The enema should be small, 
lest it cause peristalsis and quick expulsion, and ten drops of the 
tincture of opium is sometimes added to prevent irritation and 
aid retention. Five per cent, of glucose in physiologic salt solu- 
tion, or in a 0.5 per cent, sodium bicarbonate solution is one of 
the best treatments to prevent acidosis. A little calcium may 
also be added. Many times the best method of administering 
glucose solutions is by the Murphy drip, but at other times this 
method frets the patient so much that injections are better given 
once in six hours. A pint of the 5 per cent, glucose solution may 
be given once in six or eight hours. 

C. S. Bacon, 1 discussing the treatment of pernicious vomiting 
in pregnancy, suggests the following nutrient enema, which 
seems to have a very rational foundation. He gives a cleansing 
enema between seven and eight o'clock in the morning; then the 

1 The Journal A. M. A., June 8, 1918, p. 1750. 



606 THE PRINCIPLES OF THERAPEUTICS 

nutrient enemas are given at 9 A. M., 2 P. M. and 7 P. M. 
Sometimes he adds tincture of opium to these enemas. He 
suggests the following proportions : 

Glucose 50. Gm. 

Alcohol 50 . mils 

Calcium chloride o . 30 Gm. 

Sodium bicarbonate 3 . Gm. 

Sodium chloride 4 . Gm. 

Vitamine "as much as is sufficient." 

Distilled water up to 1000 mils. 

From 300 to 500 mils of this mixture is given three times daily, 
and he estimates that the whole represents 550 calories. The 
vitamine in the above mixture may well be furnished by a small 
quantity of yeast or of butter. 

Life cannot be sustained by rectal injections of nutriments 
for more than five or six weeks at the most; but before this 
period has ended, unless the case is an incurable one, the emer- 
gency will have passed. Also it should be remembered, in 
estimating the value of rectal feeding, in practice it is never 
resorted to until the patient is almost starved, and more or less 
acidosis is present. 

In all cases of rectal feeding the mouth must be kept clean. 
Bromides may be given by rectum if the patient is very nervous. 

The following is a proportion for a glucose solution: 

Sodium chloride 2 . 50 Gm. 

Glucose 25 . Gm. 

Water 500 . mils 

This amount may be given three or four times in twenty-four 
hours. One of these injections each day should contain some 
calcium, and the following may constitute one of the enemas. 

Calcium glycerophosphate 5 . Gm. 

Glucose 25. Gm. 

Water 500 . mils 

If it is advisable to give alcohol, one of the injections may be as 
follows : 

Whiskey 25. mils 

Water up to 250 . mils 



GENERAL DIET CONSIDERATIONS 607 

Rectal feeding is advisable in pernicious or persistent vomit- 
ing; sometimes in ulcer of the stomach; in cancer of the stomach; 
when poisons have been taken that have caused serious inflam- 
mation or erosion of the stomach; in esophageal stricture; 
sometimes in coma from diabetes or other cause; and when 
there has been hemorrhage from the stomach or esophagus. 

Nutriments injected into the rectum cause, unfortunately, 
at times, an outpouring of acid gastric juice into the stomach. 
Therefore, unless contraindicated, it may be well for the patient 
to drink warm water soon after the nutrient enema, although at 
times even water may cause an outpouring of gastric juice. 
Whether water should be given will depend upon the sensations 
of the patient. With flatulence, heart-burn, and pain, water 
with or without some sedative, as milk of magnesia, should at 
times be given. 

GENERAL DIET CONSIDERATIONS 

The frequency with which food should be taken is generally a 
matter of habit, different countries being accustomed to dif- 
ferent methods of taking their twenty-four hours' nutriment. 
The majority of Americans are accustomed to three meals a day, 
although the omission of breakfast, or the omission of luncheon 
was, a short time ago, a fad much in vogue. It is not rational to 
go without food from the six or seven o'clock dinner of the 
evening until the noon of the following day. The morning 
work, which is often the most intense, is then done at a dis- 
advantage. No furnace would be so treated as to coaling, and 
the house or plant would not warm up in the morning, if the 
furnace were not coaled early and the drafts opened. The same 
is true with the individual. The temperature and vitality are 
the lowest from four to six o'clock in the morning, and to start 
the day's work with that handicap and to begin labor without 
nutriment is absurd. Generally, also, the omission of the noon 
meal is a mistake. This meal may be small, depending some- 
what upon the amount of breakfast that is eaten. 

The majority of people, to-day, eat light breakfasts as far as 
bulk is concerned, but the breakfast should represent sufficient 
nutriment. Unless the individual must do hard physical labor, 



608 THE PRINCIPLES OF THERAPEUTICS 

he should not eat meat for breakfast. Meat twice a day is 
sufficient, and for most individuals, once a day is better. The 
ordinary breakfast should consist of fruit, a cereal, toast, one 
or two eggs, a little bacon if desired, and a cup of good coffee 
with cream and sugar, unless there is some reason to omit these 
substances. If coffee is not taken and cocoa is taken in its 
place, the rest of the breakfast should be diminished in caloric 
value. If the breakfast cereal is omitted, the individual 
may have more toast, or bread in any form he prefers. If eggs 
are omitted, he should eat more carbohydrate. Sugar and 
cream on cereals should be recognized as so much more food. 

If there is stomach or intestinal indigestion, especially where 
there is flatulence, the gummy cereals should be avoided, but 
the dry cereals may be taken, if properly chewed. Starchy foods 
should not be eaten too rapidly; they should be thoroughly 
comminuted and mixed with saliva. Rapidly eaten, gummy 
cereals, especially masses of solidified oatmeal, is one of the most 
potent causes of intestinal indigestion in America. Many 
individuals think if they have eaten their oatmeal in the morn- 
ing, they will remain in fine health all day. In other words, 
oatmeal has become a fetich. It is one of the best of nutriments 
when strained, or properly broken up into small fragments, 
and then not eaten too rapidly. 

The luncheon must vary in the amount of nutritive value 
depending on the individual's work, and, of course, on the age 
of the individual. The growing child must have plenty of 
nutriment three times a day, and often better four times a day. 
The noon luncheon may represent a small amount of each 
kind of food, as a sandwich and a glass of milk, and a little 
fruit perhaps; or cold boiled eggs; or a salad and a cup of 
tea or cocoa; or bread and milk; or crackers and milk; or 
any combination that does not represent too much food. It 
is generally understood that the individual cannot spend too 
much time at his luncheon, and must immediately hasten to 
his duties. This means, then, that theoretically the largest 
meal had better be taken at night after the work is done, when 
a person has more time to enjoy his food, need not rush his 
eating, and may quietly rest a while afterwards. However, 



GENERAL DIET CONSIDERATIONS 609 

most working men, when they can obtain it, have their heartiest 
meal in the middle of the day. It is all a matter of habit, and 
the body soon acquires the habit of the individual and expects 
its food and nutriment daily in about the same way. Irregu- 
larity of hours of eating and irregularity in the amounts of 
food taken are not best for the physiologic processes of the 
system. The relation of the organs of digestion and their 
secretions to the organs of elimination and their excretions 
is like any other machinery that needs to be supplied with fuel, 
lubricator, and activators, as drafts, to quickly start the 
machinery and to get up steam, and some means to keep the 
apparatus cool and to free it of ashes and gas. Any interfer- 
ence with the regularity of furnishing these necessities, if 
frequently repeated, will upset the machinery and be of dis- 
advantage to the individual. 

The temperature at which the food should be taken is about 
that of the body, namely, about ioo° F. Too hot or too cold 
foods or drinks, taken on an empty stomach, may not only 
cause a serious reflex effect, through the pneumogastric nerves, 
on the heart, but may cause chronic gastric catarrh, and even 
an acute injury to the mucous membrane which may lead to 
ulcer of the stomach. Hot drinks will slightly increase the 
temperature of the body; cold drinks and iced foods will 
slightly lower the body temperature. 

Violent exercise after meals is inadvisable, although it may 
not be well to lie down and sleep after a meal. Nevertheless, 
young animals and infants sleep after full meals; and many 
patients sleep better at night by taking some simple nutriment 
into the stomach, such as hot malted milk, or crackers and cheese 
(if the patients digests cheese well), or even some fruit which 
acts well as a laxative. If a patient has indigestion, this may 
be made worse by taking food before going to bed; it may cause 
him to be sleepless and dream. However, many a wakeful 
patient, by taking simple, warm food into his stomach, causes 
sufficient dilatation of the blood-vessels of the abdomen to pro- 
duce the normal anemic condition of the brain for sleep. 

A person who is too tired from work or exercise should not eat 

until he is rested. Mental fatigue, worry, and sorrow will slow 
39 



6lO THE PRINCIPLES OF THERAPEUTICS 

digestion by inhibiting the production of gastric juice and per- 
haps also by preventing normal peristalsis and thus causing 
stasis of food in the stomach and intestines. Severe pain, 
whether in the abdomen or in other parts of the body, will 
also inhibit digestion. This is typically true of headache. 

The heat of the body is increased by taking food and by 
exercise, by exercise especially. At the same time the elimi- 
nation of heat is also increased, so that the temperature of the 
body remains the same. In cold weather more food is needed, 
however, than in warm weather, to keep up the temperature 
equilibrium. In spite of our thermometers being generally 
marked as normal for a Fahrenheit temperature 98.6, as a 
matter of fact, when the temperature is taken in the mouths of 
normal, well individuals, it is rarely as high as 98.6, and ranges 
normally from 97.8 to 98. 2 °. 

It is now generally recognized that starvation in feverish 
processes, except for the first day or two perhaps, is a mistake, 
as increased temperature not only uses up the food, but also 
begins to burn the patient's tissues, first his fat and then his 
muscles. Therefore to preserve his tissues from degeneration 
he should receive nutriment sufficient to prevent much loss, 
especially muscle loss. Of course the food must be that which 
is most easily digested, and the higher the fever the more 
liquid the food should be. 

It has already been noted that natives of cold climates 
require more fat, oils and protein foods, while those of warm 
climates require mostly carbohydrate and fruit foods ; but it is a 
mistake for an individual going from one climate to another to 
adopt absolutely the diet of the natives of that region. When 
we travel from the temperate climate to the arctic climate we 
need more starches than the natives, and when we travel to the 
tropical climates we need more protein than the natives. 

After middle age the food requirement diminishes, and in old 
age it is considerably less than the average requirement for an 
adult. This lessened requirement is probably largely owing to 
the diminished amount of exercise, and to a more sluggish 
metabolism. 

The vegetarian fad, which is in evidence among some sets of 



DIETS 6ll 

people in our own country, among those who believe in Fletcher- 
ism and among those who have experimented scientifically on 
the ability of the individual to work on a vegetable diet as 
compared with a mixed diet, should not be adopted generally 
by the inhabitants of this climate. In a large part of the 
United States for instance, the rapid changes of temperature 
require a wonderful mechanism to keep the individual well and 
his inside temperature always the same. Also the strenuosity 
of the age and the multiplicity of pathogenic germs that are ever 
present in all of our crowded communities, require an enormous 
amount of resistance, and there would seem to be but little 
question that a mixed diet containing a sufficient amount of 
proteins, especially meat proteins, produces the best average 
immunity. 

To exactly determine the excretion of salts from the body and 
what may or may not be retained in disease, the amount and 
character of the food must be known for at least seventy- two 
hours, and the total twenty-four hour urine and feces of the 
third day must be examined. Many times a disturbance of 
metabolism is thus discovered which could be determined in no 
other way. 

If the urine is too alkaline, or its alkalinity is too long con- 
tinued, irritation of the bladder occurs, as well as deposits of 
phosphates. Therefore, although alkaline drugs may be 
needed for the body, they should not be too long continued. If 
the intake of salts is increased, the output of urine is increased 
to eliminate them. The body then desires water, and there is 
thirst, and more water must be drunk. 

DIETS 

Before suggesting specific diets it should be noted that pota- 
toes, oatmeal, rice, corn-meal and hominy furnish perhaps the 
most carbohydrate nutrition for the money expended; that the 
animal fats are better for the body than the vegetable fats; and 
that pure oleomargerine, if made with animal fats, is a valuable 
food. Hot bread and cakes, hot rolls, griddle-cakes and dough- 
nuts are not very good foods for children. Milk is a most 
valuable food for children, and eggs, even if the cost is great, 



6l2 THE PRINCIPLES OF THERAPEUTICS 

furnish more nutrition for the money expended than most pro- 
tein foods. Cocoa is a valuable food and drink for children. 
Fresh fish properly prepared is a useful change from meat for 
older children as well as for adults. The non-oily fish are 
typically bass, blackfish, codfish, halibut, and swordfish. The 
oily fish are typically eels, bluefish, shad and mackerel. 

Mutton contains the glyceride of stearic acid, and pork con- 
tains the glycerides of palmitic and oleic acids. Raw or im- 
perfectly cooked meat, especially pork, is dangerous on account 
of the possibility that it may contain parasites. 

The spices are called carminatives because they promote 
peristalsis. In small amounts they are stimulant to the appe- 
tite and digestion, but in large amounts they delay digestion, 
and cause more or less irritation, often constipation, and may 
irritate the kidneys. 

Foods that increase the secretion of the gastric juice are meat 
broths, hard toasted bread and toasted crackers. Toast and 
dried bread are easier of digestion than fresh untoasted bread. 
Sometimes some of the sour fruit juices are stimulant to the 
stomach. 

The foods that inhibit a too great secretion of hydrochloric 
acid are the fats, as butter, olive oil, and cream. Ice cream and 
most cold foods are less stimulant to the stomach than are hot 
foods. 

Indigestion. — The proper diet in dyspepsia and in intestinal 
indigestion cannot be outlined without a determination of the 
cause of the condition, and hence its detailed discussion would 
go too far astray for a chapter on foods. The diet may or may 
not be at fault, though rapid eating, and too much sugar, oatmeal, 
coffee, or ice water may be the cause. The cause of the indiges- 
tion may also be eye-strain, chronic disturbance of the appendix, 
gall-stones, ulcer of the stomach or duodenum, alcohol, tobacco, 
or general nervous tire. It may be wise to give the patient 
absolute rest and a starvation diet for a few days, or only cathar- 
sis and a modified diet, all depends on the diagnosis. Hence the 
diet to correct the indigestion must be studied in conjunction 
with the disease or condition that causes it. Suffice it here to 
state that no clinical history is complete without a more or less 



DIETS 613 

careful (depending on the illness) survey of the foods and liquids 
taken by the patient, the approximate amounts, the frequency 
and the regularity of the meals, and the length of time devoted 
to the meals. 

The diet for patients with diarrhea must also be decided by 
the diagnosis of the cause. Briefly, an acute diarrhea requires 
a purge, abstinence from food, plenty of water taken, and bis- 
muth subcarbonate and salol or bismuth subcarbonate and 
sodium bicarbonate as medication. The first food allowed 
should be meat broths or milk toast or cereal, tea or cocoa, as 
deemed advisable. Later the diet should consist of eggs, meat, 
rice, baked potato, till finally the patient is allowed his regular 
mixed diet. 

In ordinary so-called dyspepsia all soups, fried foods, lobsters 
crabs, oily fish, and fatty foods should be avoided. All the 
vegetables that are hard to digest, as sweet potatoes, cauli- 
flower, cabbage, string beans, turnips and beets, should be 
omitted from the diet. Ice water before and with meals should 
not be allowed, and many times tea and coffee are inadvisable. 
It should be noted that some fruits and vegetables are more 
prone to cause gas than others; also sugar favors fermentation. 
The individuality of the patient should be studied in consider- 
ing the fruits and vegetables that should be allowed. 

Constipation. — It is almost the crime of the age, especially 
in the United States, that the majority of individuals must rely 
on laxative drugs to have daily movements of the bowels. 
While it is not proposed here to discuss the whole subject 
of the treatment of constipation, it may be stated that its 
principal causes are lack of regularity in going to stool; in- 
sufficient amount of water drunk; too refined or too concen- 
trated foods eaten without enough roughage; and an insufficient 
amount of walking or other simple exercise. 

Obviously the intestines cannot act well if they have no 
residue to act upon, and peristalsis is not active and efficient 
without a normal amount of semi-solid substances in the intes- 
tines. Stasis in the intestine from any cause tends to allow 
fermentation, putrefaction and the production of gas, and gas, 
by its own pressure, may prevent the normal onflow of fecal 



614 THE PRINCIPLES OF THERAPEUTICS 

matter. Constipation tends to putrefactive changes and to 
indicanuria, and may cause loss of appetite, headache and other 
symptoms of toxemia. Constipation may, however, be long 
tolerated by some individuals with immunity. 

The most laxative foods are the fruits, and of these prunes, 
figs, and melons are generally the most effective. Apples and 
oranges are laxative to most people, although occasionally 
oranges fail to cause such an effect. Tangerines are generally 
more laxative than oranges, while grapefruit is not as likely to 
be laxative. Grapes, plums, peaches and pears may be laxative. 

Fats and oils are laxative to some people, and in children 
simple olive oil often causes satisfactory movements of the 
bowels. Mineral oil, or an emulsion of mineral oil is now much 
used for its laxative effects. It is, of course, not a food, and 
on account of its coating the intestine and interfering with 
normal intestinal secretions should probably not be used for 
any long period. 

The laxative vegetables are those that contain a good deal 
of cellulose, or roughage as it is termed, parts which do not 
digest but pass through the intestine en masse. The most 
laxative vegetables are corn, cabbage, cauliflower, onions, 
squash, parsnips, turnips, and pumpkin. 

Sugary preparations are often laxative, as syrups, honey, 
figs, and some jellies. 

Graham bread and rye bread are more or less laxative, but 
a popular laxative food to-day is bran, and bran biscuit, bran 
bread, and bran crackers are much used. Bran contains 20 per 
cent, of almost indigestible cellulose, hence after digestion there 
is left much residue to be acted upon by the muscular coat of 
the intestine, and constipation is frequently due to a diet of 
too completely digestible food, which leaves little upon which 
peristalsis can act. When constipation is caused from too 
completely digested food with little debris, the fecal substances 
remain too long in the intestine and become dry and difficult 
of expulsion. In such cases bran is a useful laxative. 

Agar-agar is a laxative of value because it absorbs and 
retains water, and this causes the feces to be softer and therefore 
more easy of passage through the intestines. Agar-agar may be 



DIETS 615 

obtained in small pieces or as a powder, which may be eaten with 
any breakfast food. 

Bananas are laxative, and when thoroughly ripe are a good 
food for children. They also retain water and soften the 
stools. 

One of the most useful laxatives is yeast, and both dried 
brewers' yeast and ordinary compressed yeast are efficient. Be- 
sides the laxative effect of yeast, it has the ability to change 
the flora in the intestine and to more or less check fermentation. 
It should be much more frequently given in illness in which there 
is intestinal disturbance, especially if it is associated with 
constipation. The dose is enough to cause movement of the 
bowels, and it may be given in divided doses, three times a day, 
or in one dose at night. One-third to one-half of a compressed 
yeast cake dissolved in a glass of water is generally sufficient, 
and the taste is only that of a sour drink. The dose of dried 
brewers' yeast is about one-third of a teaspoonful once or twice 
a day. Yeast is also of value in infections, and at times is an 
appetizer, because it contains an active vitamine. The dose 
for this purpose is 1 Gm. (15 grains) three times a day, with 
the meals. 

Gastric Hyperacidity. — The saliva should be about neutral 
in reaction or faintly alkaline; the normal gastric acidity is 
about Jfo normal hydrochloric acid. It is doubtful if there is 
always an excess of acid when there are symptoms of hyperacid- 
ity; also an excess of acid may be present without any symptom 
of discomfort. When there are symptoms of hyperacidity the 
cause should be sought and the condition treated. 

An increased amount of oils, butter and cream should be 
taken, sugar should be reduced to a minimum, and often there 
should be a diminution of the carbohydrate foods. Sodium 
bicarbonate should not be given except as a temporary symp- 
tomatic treatment. Milk of magnesia or magnesium oxide, 
calcium in some form, and sodium or potassium citrate are often 
of value in hyperacidity. Atropine or belladonna preparations, 
so much lauded for this condition, are not successful in check- 
ing the hyperacidity, and may do harm by inhibiting other 
secretions. 



6l6 THE PRINCIPLES OF THERAPEUTICS 

Intestinal Bacteria. — There must always be some bacteria 
in the intestine; some are necessary and are always harmless; 
some are normally present, and are normal in the intestine but 
pathologic if they wander to other parts of the body. There 
are also very frequently pathologic bacteria that are harbored 
in the intestine from some previous illness or from migration 
from other parts of the body, and there are patients who carry 
pathologic bacteria in their intestines for months and even 
years. Such patients are termed carriers. 

Putrefactive bacteria may be removed from the intestines 
by changes in diet, and radical changes in the food ingested will 
also cause radical changes in the intestinal flora. A change 
from largely animal proteins to a milk and cereal diet, or even 
to a vegetable protein and carbohydrate diet will, in a few days, 
change the character of the intestinal bacteria. Milk and milk 
sugar will rapidly substitute acidophilic flora for the proteo- 
lyzing type which predominates in the intestines when animal 
protein food is eaten. Cane sugar is so rapidly absorbed that 
it is not nearly as efficient an addition to milk as is lactose, sugar 
of milk, which is more slowly absorbed, and hence passes much 
farther along in the intestine. 

Rettger believes that nursing infants are generally free from 
putrefactive bacteria because of the preponderance of B. Aci- 
dophilus in their intestines caused by the lactose in the mother's 
milk. If, in babies, toxemia from intestinal putrefaction occurs, 
a diet without animal protein, as milk, and composed largely of 
lactose and other carbohydrates will generally free the intestine 
of putrefactive germs in a few days. If the child is constipated, 
the addition of a malt sugar to the diet, especially in artificially 
fed infants, is often advisable. 

The "New and Nonofficial Remedies" of 1920 recognizes as 
satisfactory malt sugar preparations, Mead's Dextri-Maltose 
and Borcherdt's Malt Sugar. 

Rettger long ago showed that the B. Acidophilus of Morro and 
the B. Bifidus of Tissier, members of the aciduric or lactic acid 
group, are commonly found in the intestines of man, and vary 
from a few to such large numbers as to be the prevailing type 
to the exclusion of other forms of bacteria. Infants on mothers. 



DIETS 617 

milk may have the B. Bifidus dominate all the other organisms 
in the intestine. Diarrhea may cause an increase of the aciduric 
bacteria. When a large amount of lactose is taken by an adult, 
it causes, even on a mixed diet, a change of the intestinal flora 
until the B. Acidophilus is largely increased in numbers, and it 
may become the dominant germ, while the B. Bifidus is less 
prominent. Colon bacilli are rarely absent from adult intes- 
tines unless there is some serious condition, as perhaps cholera. 
This bacillus is generally absent from nursing infants. 

The B. Bulgaricus, which is so much in vogue to-day for the 
treatment of intestinal putrefaction and to prevent the absorp- 
tion of toxins in hypertension, Rettger and others have shown 
cannot be transplanted into the intestines. The administration 
of this bacillus seems at times to aid the growth of the B. Aci- 
dophilus, and what good it does is probably due to the latter 
bacillus. Consequently, Rettger believes that the most sensi- 
ble treatment to change the intestinal flora and to eliminate 
putrefactive germs is to give cultures of B. Acidophilus, and 
there is no better method than to give it as milk soured with 
that germ. The daily amount required of this acidophilic milk 
is from a pint to a quart. Rettger finds that if 100 grams of 
lactose is added to a pint of this milk the effect is as rapid and 
as satisfactory as when double that amount of the acidophilic 
milk is taken. 

Focal infection in the mouth and gums, root infection of the 
teeth, diseased tonsils and sinus infection all allow not only 
absorption of toxins, but cause to be swallowed streptococci and 
other germs; hence such conditions must now be recognized as of 
the greatest danger to civilized mankind. The alimentary 
canal disturbances caused by such germs have been thought by 
surgeons and bacterial investigators to range from ulcer of the 
stomach and duodenum to appendicitis, to say nothing of the 
possibility of transplanting these bacteria into the intestines, 
provided that the gastric juice was not sufficient to destroy the 
germs. It is not beyond the range of possibility that the in- 
crease of cancer of the stomach may not be due to such focal 
infections. Therefore while health boards are causing all restau- 
rants, grocery stores, markets, slaughter-houses, milk produc- 



6l8 THE PRINCIPLES OF THERAPEUTICS 

ing concerns, etc., to become sanitary, and expert inspectors 
insist upon proper handling and canning of foods, the physician 
and the dentist must insist that the mouths of the human race 
be kept free from bacterial infection, and then gastrointestinal 
bacterial disturbances will be much less frequent. 

Chronic poisoning from intestinal putrefaction causes loss of 
appetite, indigestion, disturbances of blood-pressure, insomnia, 
insufficiency of the liver, and a gradually developing insuffi- 
ciency of the kidneys. The part that intestinal infection and 
toxemia may play in the condition termed cardiovascular-renal 
disease has long been recognized by the medical profession, but 
undoubtedly the phrase "intestinal toxemia" has been over- 
worked, and before it is decided that such a condition is present 
more scientific examinations must be made. Increased bac- 
terial infection is shown by an increased amount of skatol, 
indol, phenols and hydrogen sulphide in the stools, and by an 
increased amount of indican, sulphates and aromatic oxy acids 
in the urine. 

Ptomaine poisoning is a phrase that has been over-used and 
made to cover many conditions which are not due to bacteria 
of putrid or dead tissue, but many serious conditions are caused 
by the ingestion of substances as well as bacteria that are 
poisonous to the body, largely depressant poisons. 

Toxins in milk, ice cream and cheese, as long ago pointed out 
by Victor C. Vaughan, may cause most serious poisoning. Fatal 
poisoning by toxins produced in imperfectly sterilized canned 
preparations (botulism) are becoming more frequent. Such 
poisoning must be prevented, as the treatment is very unsatis- 
factory. 

Briefly, the best treatment for the eradication of undesirable 
bacteria and toxins that may be in the intestine, and especially 
of the putrefactive bacteria in the lower intestine and colon, is: 
(i) a dose of calomel, later followed by a saline cathartic, unless 
the condition contraindicates such treatment; (2) abstention 
from all food from twelve to twenty-four hours, unless the condi- 
tion contraindicates such privation; (3) copious drinking of 
water; (4) phenyl salicylate, 0.30 Gm. (5 grains), in a capsule or 
powder administered every two hours for ten doses, for an 



DIETS 619 

adult; (5) milk, cereal gruel, rice, or any other carbohydrate 
food for several days; (6) lactose (sugar of milk) 50 Gm. (about 
ij^ ounces) administered four or five times a day. 

It may be wise in most chronic infection of the bowels and 
many times in acute infection to administer milk soured by the 
B. Acidophilus, which may soon cause this germ to predominate 
in the intestines to the eradication of pathogenic and putre- 
factive germs. 

Diet in Fever. — This book is not the place for a descrip- 
tion of the dainty preparations produced in a diet kitchen, or 
of the methods of preparing simple foods for the sick. Here 
can only be outlined the generalities in the treatment of fever 
patients. In the first place, the higher the fever, the more 
liquid must be the diet, and it must be that which is the most 
easily digested. In the second place, a patient with fever must 
receive food enough to satisfy the ordinary needs of the body 
at rest, and he must receive sufficient calories to supply the 
extra amount of fuel used during the feverish process, else he 
will not only soon lose his reserve glycogen, but he will lose his 
fat, and may later have degeneration of his muscle tissues. It 
should also be emphasized that a patient with fever requires 
a large amount of water, and if he does not happen to be thirsty, 
or is stupid from his illness, quite generally too little water is 
ingested. 

Milk is not always the best food, especially as a total food, 
for a fever patient. It is often not well digested by adults, and 
may cause fermentation and a large amount of gas in the 
stomach and intestines. However, a certain amount of milk, 
depending on the individual and his age, should be a part of 
most diets for the sick. The different methods of offering milk 
have already been discussed, and some methods of giving eggs 
have been noted, and an egg is very generally digested as well 
as is milk. Toast water, barley water, cocoa, tea and coffee, 
may all at times furnish drinks and foods for the sick. Orange- 
ade, lemonade, orange juice, and oranges eaten with the pulp, 
all furnish necessary fruit juices and should generally be given 
to a sick patient. Clam broth, oyster broth, and even stewed 
oysters or chopped round clams in broth, make a change of 



620 THE PRINCIPLES OF THERAPEUTICS 

taste for the patient and offer food that is easy of digestion. 
Beef juice, beef tea, mutton broth and chicken broth are all 
valuable additions to the diet. Beef tea is a stimulant only 
and a promotor of appetite and of gastric secretion, but fur- 
nishes many excretory meat products, hence should not be 
given in kidney insufficiency. 

Beef juice is well made by chopping round steak, covering it 
with water, letting it stand for two or three hours, and then 
squeezing out the juice and serum with a meat squeezer. The 
juice is placed in a refrigerator, and salted before serving. 
The juice and serum from one pound of steak is sufficient for 
twenty- four hours' feeding, given in three or four divided 
doses. 

Gelatin flavored with orange, lemon, sherry or brandy, 
makes a very pleasant nutriment. Ice cream slowly eaten is 
also generally well accepted by the stomach. 

Oatmeal gruel or other thin cereals, or if the patient is not 
very sick, milk toast or dry toast, or any cereal that requires 
chewing, may be given the patient. 

It should be emphasized that if the patient is not too ill, it is 
well for him to chew, in order to thus clean his teeth, to start 
the flow of saliva and to insalivate his food. If the patient is 
too ill to masticate his food, the teeth should receive extra fre- 
quent attention by cleaning them, and by mouth washes. Be- 
fore each meal the mouth shoulc be cleansed with some wash, 
and a saturated solution of boric acid flavored with winter- 
green or peppermint is satisfactory. Or a more elaborate and 
very good mouth wash is as follows: 

]$ Bisulphate of quinine o.io Gm. 

Boric acid 5. Gm. 

Syrup of ipecac 25. mils 

Glycerin 25. mils 

Peppermint water to make 200. mils 

Dilute a tablespoonful with an equal part of warm water and 
use with a tooth brush or as a mouth wash. 

A suggestion for the twenty-four hour diet of a typhoid fever 
patient is the following, which may be modified to suit the indi- 
vidual patient, or modified to suit other fevers. One pint of 



DIETS 621 

milk; 2 eggs; one cup of well cooked oatmeal gruel; the juice 
expressed from a pound of chopped round steak; a cup of coffee 
in the morning; a small portion of gelatin; and water given at 
intervals throughout the twenty-four hours. He should have 
enough salt and sugar to flavor his food. If for any reason he 
is on a more restricted diet, salt should be added to his milk, and 
sugar should be furnished him in some form, perhaps as lactose, 
but sugar he should receive. 

He should be fed at frequent intervals during the day-time, 
and perhaps best every three hours, and every four or five hours 
during the night, depending upon the amount of food that he 
takes. The less the food taken, the shorter must be the interval ; 
but ordinarily he should not be awakened when he is sleeping 
quietly and comfortably for either food, medicine, or cold 
sponging. A patient with fever, and a typhoid patient especially, 
is too often disturbed during his sleep for one of the above 
reasons. A patient with fever requires rest. 

The diet may be gradually increased after the fever stops, 
first by the addition of bread, rice, baked potato, a small 
cheese sandwich, apple sauce or other simple cooked fruit. 

Anemia. — In anemia and debility, especially if there is not 
much appetite, thin, bulky foods without much nutrition should 
not be allowed. Greasy and fatty foods which require a very 
active digestive apparatus, are also generally not advisable. The 
various vegetables with little nutrition and considerable rough- 
age such as cabbage, turnips, squash, etc., had better be omit- 
ted from the diet. Salted meats, except perhaps ham, should 
not be allowed. Thin soups carry but little nutrition and are 
generally inadvisable, although a small cup of good beef broth 
is a gastric stimulant. Such desserts as pies and rich pastries 
should be omitted from the diet. The food given should be 
the most nutritious possible, offered in the most tasty manner. 
If not much food can be eaten at any one meal, more frequent 
meals should be given, and such foods should be urged as will 
present the most nutriment in the smallest bulk. If any partic- 
ular food is desired or craved, even if it is not nutritious, it 
should generally be allowed such a patient. Small doses of 
yeast at times stimulate the appetite, owing to its vitamine 



622 THE PRINCIPLES OF THERAPEUTICS 

content. Some simple bitter tonic taken before meals may be 
advisable. 

Heart Disease. — With heart disease the constant aim 
should be to give a nutritious diet that is easily assimilated and 
that will cause the least indigestion. Any distention of the 
stomach is likely to increase the cardiac disturbance. If dropsy 
occurs, with or without kidney insufficiency, the so-called Karell 
treatment may be carried out more or less rigidly. This treat- 
ment consists of the administration of 200 mils of milk in four 
doses at four hour intervals during the daytime, and if rigidly 
carried out, this treatment is continued for a week. The milk 
may be taken hot or cold, as the patient desires, but other 
food is not allowed. At the end of this rigid dietary treat- 
ment, which frequently should not last the whole week, the 
patient is allowed an egg and a slice of dry toast a day. After 
two or three days another egg is added, with bread, rice, or 
other cereal each day, and in about two weeks the patient is 
back to his modified normal diet. Whether he should have 
small amounts of meat depends upon the sufficiency of the kid- 
neys. During this period the bowels are generally moved by 
enema. If thirst is suffered, and it should be noted that this 
diet should be more or less free from sodium chloride, the 
patient may be allowed small amounts of water. It is often 
wise to add milk sugar to the diet. 

More or less intensive treatment with digitalis is generally 
indicated. 

Salt-free Diet. — A salt-free diet may be necessary in kidney 
insufficiency, and is of advantage in cardiac and renal edemas, 
and is at times of value in inflammations of the skin and in 
simple pruritus. This diet should consist of food that is easy 
of digestion, and the meats, potatoes and other vegetables 
should be cooked and eaten without salt, and even the bread 
should be made without salt. If there is edema, the amount 
of water taken should be limited; if there is no edema, plenty 
of water should be allowed. Buttermilk often makes a good 
addition to this diet. 

In kidney disease urea is more easily excreted than many of 
the substances that are eliminated by the urine; hence it is 



DIETS 623 

often a mistake in chronic insufficiency to withhold all meat 
and increase other foods. 

Doubtless kidneys are damaged by over-eating protein foods 
over long periods, but much more likely to damage the kidneys 
is the insidious irritation caused by long continued focal 
infection. 

Hypertension. — With high blood-pressure the purin foods 
should generally be removed from the diet. Meat should often 
be omitted from the diet, or allowed at most but once a day, 
and coffee_and tea should generally be prohibited. There must 
be daily free movements of the bowels, and it should be recog- 
nized whatever else is causing the high blood-pressure, 
decomposition and putrefactive products in the intestine when 
absorbed tend to raise the blood-pressure by irritation of 
the nerve centers, and also there may be produced in the 
intestines actual blood-pressure- raising substances. When there 
is intestinal putrefaction animal protein must be for a time, 
at least, prohibited, and the intestinal flora should be changed 
by lactose and a starch diet, and the protein food allowed 
should be gelatin, vegetable proteins and nuts. Plenty of 
fruit should be eaten and plenty of water drunk. 

Diet in Pregnacy. — It is not ordinarily necessary to en- 
courage the pregnant woman to overeat, although certain salts 
in extra amounts may be required, perhaps particularly calcium 
salts. It seems to be the fact that the placenta has the ability 
to select from the mother's blood the nutriment needed for 
the development of the child. Overfeeding of the mother is 
likely to cause toxemia rather than to be to her advantage. 

The nausea of pregnancy is apparently a form of toxemia, 
and while this condition is almost constant in the early months 
of pregnancy and is tolerated by many women without complaint, 
neglect of the condition may cause the development of perni- 
cious vomiting. Such patients should drink plenty of water, 
but should increase the carbohydrate intake, as they readily 
develop an acidosis. 

Whatever mistake there may be in the endocrine glands, and 
whether or not thyroid extracts are indicated, not only carbo- 
hydrates, but alkalies should be given. The mother needs 



624 THE PRINCIPLES OF THERAPEUTICS 

not only glycogen for her own use, but the placenta has been 
shown to be the storage for glycogen for the fetus until the 
fetal liver functions. 

When there is profuse and frequent vomiting during pregnancy, 
the mother's liver is depleted of its glycogen and the needs of 
the fetus and uterus for glycogen is interfered with, and extra 
carbohydrate feeding is urgently demanded. Also, when there 
is much vomiting and water is not well retained, the mother 
must have it, and, if the stomach will not retain it, she must 
have colon injections of water to which it is often well to add 
glycogen. It is also generally advisable to add sodium bicar- 
bonate to the fluid to be injected. 

Tuberculosis. — It has been learned that in the treatment of 
this disease hyperalimentation is not necessary, and does harm ; 
large amounts of meat and many eggs are inadvisable. A few 
eggs a day, meat once, or at most twice, a day, plenty of good 
carbohydrate food, fresh vegetables, some fruit, plenty of butter 
and cream, and some good milk, represent the nutriment these 
patients require. Besides the regular three meals, extra nutri- 
ment may be given in the middle of the morning, the middle 
of the afternoon, and, generally, at bedtime. The extra food, 
if it agrees, is generally milk. If it does not agree, some other 
simple food, as bread, cake, malted milk, nuts, or a cheese 
sandwich, will offer the nutriment desired. However, some 
patients do better on only three meals a day. 

Diabetes Mellitus. — It is not intended to discuss the whole 
treatment of diabetes, but to briefly outline the Allen- Joslin 
diet, and to list the carbohydrate values of some foods. The 
treatment consists of starvation until the patient's urine is free 
from sugar, unless during the starvation period symptoms 
develop that require carbohydrates to be administered. The 
appearance of diacetic acid, betaoxybutyric acid and acetone 
in the urine is not now considered, necessarily, an indication to 
immediately cease the starvation treatment, as patients can 
tolerate a certain amount of acidosis for a short length of time. 
Plenty of water should be administered, and often some alkali, 
generally best sodium bicarbonate. For a few days before the 
starvation period the patient should be deprived of all fats, as 



DIETS 625 

it is the fats that tend to increase the acidosis. At times whiskey 
has been given in good sized doses during the starvation period, 
as tending to prevent acidosis and offering many calories for the 
body to burn. It is not always advisable, however, to give 
alcohol. The patient may have, during this starvation period, 
tea or coffee without milk or sugar, and sometimes a little meat 
broth. During the starvation period the patient should be in 
bed. 

As soon as the urine is sugar-free, small amounts of vegetables 
containing the least amount of carbohydrates are given, and 
this amount is gradually increased until sugar appears in the 
urine. The carbohydrates are then kept below this amount, 
and then protein is gradually added to the diet until it is found 
that, with the carbohydrates, sugar again appears in the urine. 
The protein is then reduced to a little less than this amount, and 
a little fat is added. The patient is kept on this careful diet, 
and week by week a little more starch is added and the toler- 
ance noted. The patient's diet should constantly be kept 
below the point at which sugar appears in the urine. 

That a patient loses weight, or remains thin, is not a disadvan- 
tage, in fact, a patient with diabetes is perhaps better without 
his fat. 

A patient with severe diabetes, in whom sugar occurs in the 
urine on even a pretty rigid diet, may later, by great care, ac- 
quire a better tolerance for food and his condition may improve, 
provided the more or less rigid diet is long continued. Many 
patients do better with the continued administration of an alkali 
either the bicarbonate of sodium, or sodium or potassium citrate, 
during their restricted starch diet. 

The vegetables that contain 5 per cent, or less of carbohydrate 
are: spinach, string beans, Brussels sprouts, cauliflower, aspara- 
gus, lettuce, endive, tomatoes, celery, cucumbers, and egg plant. 
Cabbage and radishes contain a little more starch. Clams, 
oysters, scallops, and grape fruit contain but little carbohydrate. 
The vegetables and fruits that contain about 10 per cent, of 
carbohydrate are : turnips, carrots, onions, squash, beets, lemons 
oranges, cranberries, strawberries, gooseberries, blackberries, 
melons, pineapples, and peaches. Those that contain about 

40 



626 THE PRINCIPLES OF THERAPEUTICS 

15 per cent, are: most of the nuts, peas, lima beans, parsnips, 
apricots, pears, cherries, currants, huckleberries, and raspberries. 
Those that contain 20 per cent, or more of starch are: potatoes, 
baked beans and shell beans, corn, rice, macaroni, bananas, and 
plums. Cheese contains only about 2 per cent, of carbohydrate; 
bread about 60 to 70 per cent. ; rice about 80 per cent. ; oatmeal 
about 66 per cent. 

When the starvation period causes dangerous acidosis, or 
acidosis in a dangerous amount occurs at any time, sodium 
bicarbonate is the best antidote, and 4 Gm. (60 grains), given 
by the mouth at from four to six hour intervals, is an effective 
dose. The intravenous administration of sodium bicarbonate 
solutions, (500 mils (1 pint) of a 4 per cent, solution) injected 
slowly, is often the most efficient method of re-alkalizing the 
system. 

The first food given after the starvation period should be 
the vegetables that contain less than 5 per cent, of carbohydrate, 
and in gradually increasing amounts. As soon as sugar appears 
in the urine, another starvation day is given, then the amount 
of the carbohydrate is reduced, and protein is gradually added 
until the protein plus carbohydrate tolerance is noted. Then 
the amount of protein is kept below that which causes the ap- 
pearance of glucose in the urine, and some fat is allowed. For 
some time, and perhaps for a long time, there should be one day 
a week of fasting, except for water, coffee or tea, and possibly a 
little meat broth. Sometimes this may be termed a ''green 
day," and only the simplest green vegetables are taken. Or one 
day a week the food may be restricted to two or three quarts of 
skimmed milk. 

Instead of the absolute starvation treatment, raw starch has 
been suggested, to give a patient while he is becoming sugar- 
free. A teaspoonful of raw corn starch stirred in a glass of 
water is given three or four times a day, depending on the 
condition of the patient. With the starch treatment green 
vegetables are allowed. 

The oatmeal treatment has long been lauded, and many 
patients tolerate oatmeal starch who cannot tolerate other 
starches. 



DIETS 627 

There are on the market many flours which have had most of 
their carbohydrate removed. These are termed diabetic 
or gluten flours. Those listed by "New and Non-official 
Remedies" for 1920 are: "Barker's Gluten Food A," which 
contains 87 per cent, of protein and not more than 4 per cent, of 
carbohydrates; "Barker's Gluten Food B," which contains 
85 per cent, of protein and not more that 7 per cent, of carbo- 
hydrates; and "Barker's Gluten Food C," which contains 83 per 
cent, of protein and not more than 1 2 per cent, of carbohydrates. 
"Hoyt's Gluten Special Flour" contains 80 per cent, of protein 
and less than 10 per cent, of starch. Hepco Flour is prepared 
from the soy bean, and although containing 22^ per cent, of 
carbohydrate, it is claimed that the carbohydrates of the soy 
bean are not as likely to cause glycosuria. Another flour made 
from the soy bean is "Soy Bean Gruel Flour," which contains 
10 per cent, of starch. The soy bean flours contain considerable 
fat. 

Although boiling vegetables three times and pouring off the 
water removes most of the carbohydrates, such treatment also 
ruins their taste and palatability, and it has been found that 
if the water is poured off from the vegetables three times 
before boiling most of the starch is removed but the taste is 
unimpaired. 

Obesity. — Obesity may be a family or an individual trait. If 
an individual trait, it is likely to be due to some disturbance 
of the glands of internal secretion. Infantile obesity should 
always be considered an endocrine mistake. Normally both 
men and women add weight after forty, and after the meno- 
pause women are likely to add weight rapidly. The majority 
of women at fifty are more likely to be over-weight than the 
majority of men at that age. 

Unless there is an unusual addition of fat, the individual 
rarely seeks medical help, unless he begins to have signs of 
disability, mostly dyspnea on exertion. Unless some diseased 
condition is causing the development of fat, his digestion is 
generally good, often too good, and he eats too much fat- 
producing food, to which he is likely to add a sedentary habit, 
and actual laziness. 



628 THE PRINCIPLES OF THERAPEUTICS 

The treatment of obesity will here be discussed only from 
the dietary standpoint. It may, however, be urged that quite 
generally there is some endocrine gland disturbance, and the 
action of these glands on metabolism is constantly evidenced by 
the tendency of women to put on weight after childbirth, and 
the tendency for castrated men and women to become obese. 
When amenorrhea occurs without pregnancy, before the 
menopause, if the woman is not diseased, she always adds 
weight. Also the association, after middle life, of glycosuria 
with obesity is interesting and frequent. 

The treatment of obesity is: (1) a modification of the diet; 
(2) such glandular treatment as is needed; (3) physical exercise; 
and (4) hydrotherapeutic or other sweating measures. 

It is obvious that fats, oils, and sugars must be withheld from 
the patient; that the calories presented must be below the 
ordinary need of the individual, in order to have him gradually 
burn the fat which is deposited in various parts of his body. It 
is also obvious that he should not eat enough proteins to make 
up for the calories that are withdrawn from his food by limiting 
the carbohydrate foods. 

Various names have been given to different methods of diet- 
ing the obese. Some of them have been termed: the Banting 
system, the Epstein, the Hirschfeld, the von Noorden, and the 
Oertel. In the Banting system the proteins are increased while 
the carbohydrates are greatly diminished, and very little fat is 
allowed. In the Epstein treatment the carbohydrates are 
greatly diminished, considerable fat is allowed, and the normal 
amount of proteins. In the Hirschfeld treatment all kinds of 
food are greatly reduced; in the von Noorden the proteins are 
increased and the carbohydrates and fats are much diminished; 
while in the Oertel treatment the proteins are increased, the 
fats much diminished, and the carbohydrates very greatly 
reduced. The Karell treatment is that of an absolute milk 
diet, two to three pints a day. This is the treatment that is so 
many times given to reduce cardiac edema. The so-called 
Schweninger method greatly limits the intake of fluid. 

It is hardly necessary to adopt any one of these particular 
methods of treatment, but at the start perhaps the Karell 



DIETS 629 

treatment is the best. Later, it is best to keep the proteins at 
about the normal amount, to almost eliminate fats, and to 
reduce the carbohydrates to one-half, and if it is necessary, to 
one-third the normal amount for the age of the individual. 

To well arrange the proper diet for the obese, one must study 
the fat and caloric value of foods. The amount of water taken, 
especially at meals, should be limited, the most water to be 
drunk one or two hours before the next meal. No one meal 
should represent several kinds of food ; the more the character of 
the food is limited, the less is the amount desired. It has even 
been suggested to furnish only one article of food at a meal, 
allowing the patient to select the one he desires. It has also 
been suggested that a tablespoonful of olive oil be given just 
before a meal, which, of course, reduces gastric secretion and 
perhaps gastric contractions, and hence the appetite. The 
vegetables allowable are those that have the least caloric value, 
i.e., the five per cent, 'starch foods. The fruits allowed are those 
that contain but little sugar, and the meats allowed are those 
that contain but little fat. Appetizers must not be allowed. 

Except when on the Karell diet, milk should not be given. 
Cheese, cream, corn, nuts, olives, butter, and cocoa should be 
avoided. Lemons may be freely taken, and other sour fruits. 
Buttermilk is a valuable addition to the diet of these patients, 
provided that the other protein food is reduced in amount. If 
the individual cannot learn to take his tea and coffee, or his 
food, without sugar, saccharin may be used for a time. 

Scurvy. — Scurvy has been shown to be due to privation of 
certain vitamines which occur in the foods, and these vitamines 
are best furnished by acid fruits, as presented by lemons and 
lemon juice, oranges and orange juice, and by tomatoes. Orange 
juice may, however, fail to rapidly cure scurvy. A nursing 
child may develop scurvy if the mother's milk is too low in 
vitamines. Fresh cow's milk contains sufficient vitamines, 
ordinarily, to prevent scurvy, but sterilized milk always and 
pasteurized milk sometimes, as well as artificial baby foods, 
do not contain these vitamines. Many vegetables offer 
antiscorbutic vitamines, though they are not as satisfactory as 
the fruits above suggested. The water of boiled potatoes con- 



63O THE PRINCIPLES OF THERAPEUTICS 

tains some vitamines that will prevent scurvy. However, the 
danger from solanine poisoning from the skins of sprouting 
potatoes must be remembered. Desiccating green vegetables 
at high temperature probably kills the antiscorbutic vitamines, 
but dry orange juice has been shown to retain some of its 
antiscorbutic properties. 

Hess has found that cod liver oil will not prevent scurvy. 
McCarrison has found that a diet that tends to cause scurvy 
will also reduce the epinephrine of the adrenal glands. Scurvy 
can be caused experimentally by a privation diet. 

Rickets.- — This disease of young children has been long recog- 
nized, but the cause is still elusive. It has been lately suggested 
that it is a deficiency disease, due to privation of fat-soluble 
vitamines. 

Hess and Unger 1 have investigated this disease, and find, 
after studying one hundred infants, that it is not caused by lack 
of fresh air, that it can occur in spite of an abundance of good 
food, and that it is markedly benefited by cod liver oil. 

Cod liver oil and phosphates have long been given empirically 
for this disease, and with markedly good effect, but this does 
not disprove the fact that some vitamine deficiency may not be 
the inherent cause of the disease, even if an abundance of foods 
rich in vitamines does not prevent or even may not cure the 
disease until something else is given. That negro infants are 
more likely to have the disease than white infants, even on the 
same food, does not disprove the deficiency factor. Hereditary 
deficiencies have not yet been studied, or have the effect of 
hereditary deficiencies on the endocrine glands. Certainly, 
besides the cod liver oil and phosphates, rachitic children should 
be fed cereal, fruit and butter-fat vitamines. 

Beriberi. — Beriberi is a polyneuritis which seems to be caused 
by the privation of antineuritic vitamines, and is especially likely 
to occur in those whose daily diet is largely of polished .rice. 
Eggs, yeast, fresh cereals, fresh fruit, barley, potato, whole wheat 
bread, fresh beans and peas, and unpolished rice have all been 
shown to contain antineuritic vitamines, and when fed will 
prevent the development of beriberi. 

1 Journal A. M. A., Jan. 24, 1920, p. 217. 



DIETS 631 

Pellagra. — Pellagra has been carefully investigated by various 
commissions and although some students of this disease believe 
that there may be an infection present, it is probably incidental, 
as it seems proved that this disease is due to privation of proteins, 
and apparently of the vitamines contained in meat. Gold- 
berger and Wheeler 1 have clinically demonstrated that pellagra 
can be caused by restrictions in diet. 

Xerophthalmia. — This peculiar eye disease of infants is 
apparently due to vitamine deficiency, and probably rarely 
occurs except in real food privation. The inflammation of the 
eyes may be due to a dry condition of the conjunctivae, and 
hence a lack of resistance to germs. The disease is due to 
a deficiency in fat-soluble vitamines, and therefore especially 
occurs in long abstinence from these vitamines and from fats. 

1 Archives of Internal Medicine, May, 1920, p. 451. 



PART VIII 

GENERAL PHYSICAL MEASURES 

HYPEREMIC TREATMENT 

Local hyperemia, mostly discussed under the name of Bier's 
hyperemic treatment of disease, is produced by three methods : 
(i) by any means that obstructs the flow of the venous circu- 
lation by constriction above the affected part; (2) by dry 
cupping; and (3) by hot air. 

The object of hyperemia is to increase the quantity of blood, 
hence leucocytes and any antibodies, in the part affected. 
When constriction is applied above the affected part (not 
touching the inflamed area) it should not stop the circulation 
of the blood, it should only slow the venous return; the arterial 
pulse must always be readily felt below the point of constriction. 
The venous congestion should not cause pain, but should rather 
abolish pain, and the part below the constriction should not be 
pale, and yet not darker than a deep crimson; also the part 
must be warm and not cold. If the venous congestion lasts 
for some hours, edema below the point of constriction may 
occur. 

Though it is a frequent and apparently sometimes successful 
treatment to apply an ice bag directly to a beginning inflam- 
mation, if the part may be readily reached, theoretically this 
is not what an infected area biologically requires. Protective 
leucocytes quickly surround an infected region to seal and 
isolate the infection from the rest of the body. Therefore, in 
such a condition, theoretically, the hyperemic method is the 
better, and an abortion of the inflammation caused by the 
infection means a successful fight of the blood corpuscles and 
blood serum against the germs or virus. On the other hand, 
applications of ice or cold are of value when there is an injury 
or bruise of a part without a lesion of the skin, and hence with- 
out bacterial contamination, as such treatment tends to 

632 



HYPEREMIC TREATMENT 633 

prevent hemorrhage and excessive exudate and swelling, and 
therefore the later repair will be more rapid. 

There are various kinds of elastic bandages, etc., that may 
be used to produce constriction hyperemia in different parts of 
the body. The length of time the constricting band should 
remain applied, and its intermittency, must be decided by the 
physician or surgeon, as it depends entirely upon the condition 
for which the constriction is used and the results caused. If the 
part below the constriction is not painful at first but becomes 
painful later, the constriction should be removed, and the band- 
age re-applied less firmly. 

Dry Cupping. — The second method of producing local hyper- 
emia is by cupping. The cup is applied firmly to the skin and the 
air is exhausted from it by means of a suction syringe or pump, 
which causes a negative pressure and consequently hyperemia 
of the part encircled by the cup. Not only the skin, but the 
parts beneath the skin are sucked up into the cup, if the negative 
pressure is sufficient, but the suction should not be strong 
enough to cause pain, or sufficient for the rim of the cup to shut 
off the circulation ; the color of the part within the cup should be 
crimson and not white. 

The length of time a cup should remain on the part depends 
upon the pressure exerted. If the pressure is not great, the 
cup may be allowed to gradually fill with air, as it will, and fall 
off of itself; but if the hyperemia caused is intense, it should be 
relieved by removing the cup within a few minutes. Bleeding 
or much bruising of the tissues should not be caused. Various 
shapes of cups for all parts of the body may be obtained. 

Hyperemia by Means of Hot Air. — Hyperemia produced by 
hot air differs from the venous congestion caused by other 
methods. By hot air, or dry heat, the arterial circulation is 
increased by dilatation of the arterioles. It will be readily 
understood that increased arterial circulation tends to remove 
exudates and extravasations due to chronic inflammations, 
therefore this method of treatment is more applicable to chronic 
than to acute conditions. 

There are various methods of applying heat to the body: 
moist heat by hot baths, or locally by hot fomentations or poul- 



634 THE PRINCIPLES OF THERAPEUTICS 

tices; dry heat by electric light baths, body baking or sun baths; 
and localized dry heat by electric lamps, by diathermy, by local 
baking, by bran bags, sand bags, etc. Another method of 
applying heat to a part is by a hot air douche, as it is termed, in 
which a long tube or pipe directs hot air (best from an electric 
heater) to the part affected. Frequently beneficial is the appli- 
cation of a hot iron over a part protected by one layer of a 
dampened bath towel. The whole back may be thus treated. 
Whatever the heat apparatus used, it is often of advantage to 
have gentle massage follow it. These hot air treatments vary 
in duration depending entirely upon the part of the body 
treated and the method used. Sweating and blistering should 
be prevented by Turkish towels, if the heat is intense enough to 
cause the possibility of blistering. If the feet and hands are 
subjected to heat that may cause blistering the fingers and toes 
should be bound separately with flannel. 

Various hot air apparatus for the treatment of local diseases 
of the skin and diseases of the ear, eye, throat and genito- 
urinary organs can be obtained. 

HELIOTHERAPY 

All of the ancients recognized the value of the sun in curing 
and preventing disease, and many of them worshiped the sun. 
Though Finsen urged the value of sun baths in 1902, it is only 
recently that the medical profession has taken real scientific 
interest in the beneficial effect of sun rays in diseased condi- 
tions. Even at the present time only a very few surgeons and 
physicians throughout the world have made a study of what 
the different rays of the sun can do physiologically and thera- 
peutically to the human body. 

This is not the place to more than briefly refer to the physics 
of the various parts of the solar spectrum. It may be stated 
that the distance of the sun from the earth is 90 million eight 
hundred thousand miles, and that the light and heat rays 
travel at the rate of 186,500 miles per second, which means that 
it takes a little more than eight minutes for the sun rays to 
reach the earth. The rays from the sun which the eye distin- 
guishes is the solar spectrum, consisting, it will be remembered. 



HELIOTHERAPY 635 

of red, orange, yellow, green, blue, indigo, and violet; but there 
are rays both above and below this spectrum which the eye 
cannot recognize. At the red end are the infra red or heat rays, 
and at the violet end are the ultra violet rays. Below the infra 
red are the so-called Hertz waves and N-rays, and beyond the 
ultra violet are waves which correspond to the roentgen rays. 
The Hertz waves are short waves of high frequency and iden- 
tical with the electric waves used in wireless telegraphy. 
The ultra violet rays have been termed chemical rays, and it is 
these rays that form ozone and kill bacteria. The Finsen lamp 
has iron electrodes which increase the ultra violet rays, and this 
lamp has been used in the treatment of some skin diseases. 
The ultra violet rays may cause quite intense skin reactions. 

For advantageous action of the sun's rays on the body there 
should, ordinarily, be no intercepting clothing, and the air 
through which the rays come must be clean, not dust-laden. 
The rays that cause pigmentation, bronzing, or tanning of 
the skin are more active in the higher altitudes than in the 
lower altitudes, and the more pigment the skin contains, 
the more the rays are absorbed and the more beneficial is their 
action. As the reaction of the body is both physical and 
chemical, the action of the rays on the whole body is greater 
than when a certain part only is exposed. When any clothing 
is interposed between the body and the rays, it is the ultra 
violet, perhaps the most beneficial rays, that have their action 
inhibited. 

In beginning the sun bath exposures, the patient should 
first have part of the body exposed for a few minutes, perhaps 
the legs; the next day a larger part of the body, and so on until 
at the end of four or five days the whole body may be exposed. 
The head should always be protected. 

Undoubtedly the direct rays have their greatest therapeutic 
effect in solariums especially built for these treatments. How- 
ever, such exposures are sometimes impossible, and patients may 
then be concealed and receive reflected sunlight from mirrors. 
When the sun's rays are reflected from mirrors, the heat rays 
must be cut off. This may be done by covering the mirrors 
with blue glass. These reflected treatments are for the exposure 



636 THE PRINCIPLES OF THERAPEUTICS 

of the whole body, or of some special part. Ordinarily, 
however, in limited exposures the direct sun rays may be used. 

The dosage of the sun bath must be regulated, a short bath 
having generally a tonic effect and a long bath a depressing 
effect, especially if much perspiration is caused. The treatments 
should not be given directly after meals, and the first exposure, 
especially of the whole body, should be for only a few minutes, 
and then be gradually increased by five or ten minutes a day. 
If faintness or weakness is caused, the length of the exposure 
should be greatly shortened. If there is a tendency to much 
increased temperature, cold cloths may be placed around the 
head. Blonds seem to be more affected by sun baths than 
brunettes, and they are more likely to become burned than are 
dark-skinned individuals. Also the blond may be more 
affected nervously by the rays. 

Sun rays have been thus used to advantage in tuberculosis of 
all parts of the body, especially of the bones. A beneficial 
effect may be obtained by applying the rays directly to the 
part affected, whether bone or lung tuberculosis; still it is 
apparently more valuable to expose the whole body. It was at 
first thought that the greatest advantage, especially in tubercu- 
losis, was acquired by the use of the sun's rays at high altitudes, 
but it has been found that perhaps just as good results are 
obtained by the use of the rays in low altitudes. It should be 
understood that the sun treatment alone of tuberculosis is a 
mistake, and advantage should be taken of every other treat- 
ment found beneficial, as open air, rest, food, tonics, and, in 
proper cases, tuberculin. When these treatments are combined, 
the benefit in joint, bone, gland, skin and pleural tuberculosis 
seems demonstrated. The value of the sun rays in pulmonary 
and in abdominal tuberculosis will soon be shown by data 
presented by institutions using this treatment. 

Many other conditions are benefited by the sun rays, especially 
wounds and infections which tend to heal but slowly. Many 
kinds of skin diseases and some diseases of the blood, especially 
anemia, are benefited. By sun treatments the peripheral cir- 
culation is increased, and the blood-pressure is generally lowered. 
In debilitated conditions, if the treatment is of benefit, the appe- 



HE LIOTHE R AP Y 637 

tite will be increased and the digestion improved. If these 
effects do not result from the sun bath, the treatment is not of 
much benefit, or it is not being properly applied. 

In order to bring the use of the sun rays to the reach of hospi- 
tals and institutions and physicians ' offices where the rays of the 
sun cannot be properly applied, the Heraeus Quartz Light, or 
Alpine Sun Lamp, has been developed. The rays from a prop- 
erly constructed quartz lamp will kill bacteria by its ultra violet 
rays, and will apparently cause many, if not all, of the bene- 
ficial results caused by the direct application of the rays of the 
sun. All kinds of diseases of the skin, tumor growths, bone 
diseases, and systemic diseases are being treated by some clini- 
cians, apparently satisfactorily, with these artificial sun rays as 
furnished by these quartz lamps. The technique should be most 
carefully studied before quartz lamp treatments are given. 
Also the effect on the patient's skin must be watched, as well as 
care taken not to cause shock. 

More recently convex lenses have been used to concentrate 
the rays of the sun on sluggish ulcers and sinuses, with reported 
success. 

While many of the reports of the results of the sunlight treat- 
ment are very enthusiastic, statistics are not yet sufficient to 
declare the exact value of the treatment in many diseases. The 
benefit caused by heliotherapy in tuberculosis has been de- 
scribed. It is certainly demonstrated that various methods of 
applying violet rays to the body are of great benefit, especially 
in painful nerves and joints, and that these rays can prevent 
germ growth; also it seems demonstrated that the actinic sun 
rays stimulate healing. Consequently, it seems justifiable at 
the present time to declare that an institution for the treatment 
of tuberculosis is not complete without its solarium for the 
therapeutic use of the sun rays, and that a hospital is not com- 
plete without roof gardens, sun parlors and apparatus for the 
sunlight treatment of many conditions. 

The value of sunlight in the prevention of disease and in kill- 
ing pathogenic germs cannot be too much taught, and light, 
airy houses and tenements, sun parlors and sun porches, and 
homes in the suburbs should be the battle cry against tuberculo- 



638 THE PRINCIPLES OF THERAPEUTICS 

sis and pneumonia, the combined cause of the great majority 
of deaths in civilized communities. 

Electric lamp cabinets are much used to cause dilatation of the 
peripheral vessels and perspiration. Care should be taken in 
these treatments to keep the patients head cool and prevent 
faintness. 

Colored light may have more than an historic interest, as blue 
light is supposed to be sedative, while yellow and red lights are 
supposed to be stimulant to the patient. 

ELECTRICITY 

Although electricity was discovered over two thousand years 
ago, and seems to have been used on human beings by early 
Roman practitioners, still it was not used regularly for medical 
purposes until after the discoveries of electrical activities by 
Galvani in about 1790, by Volta in about 1800, and by Faraday 
in 1 83 1. From these sources are derived the names for the 
constant current, Galvanic, for the interrupted current, Fara- 
dic, and for the unit of electromotive force, the Volt. 

Electrical treatments have been long given both by regular 
and by irregular practitioners, and though skeptics in medicine 
believe that a large amount of the good done is by suggestion, 
still there is a large practical, useful field for the medical use of 
electricity. Its power to stimulate nerves and to cause muscle 
contraction, and therefore its ability to awaken sleeping, slug- 
gish nerves, to transmit messages along rusty wires, and to 
increase the nutrition and strength of weak and paralyzed 
muscles is unquestionable. Electricity can modify the general 
metabolism, when it is applied for this object, as evidenced by 
an increased nitrogenous output. Also the ability of this agent 
to increase the peripheral and general circulation as well as to 
improve the muscle tone can be clinically demonstrated. That 
electrical appliances, as well as the actual application of elec- 
tricity, have a favorable influence on the mind is true of any 
physical treatment, and is true of any new treatment, and even 
of treatment by a new physician or by a specialist. Favorable 
impressions on the mind should not be left to the Christian 
Scientist or mental healer. 



ELECTRICITY 639 

General Considerations. — A piece of copper wire J120 of an 
inch in diameter and 2 50 feet long represents exactly one ohm of 
resistance. The broader and shorter the wire, the less resist- 
ance it will present. 

The unit of resistance is the ohm, from Ohm; the unit of 
intensity is the ampere, from Ampere. An ampere represents 
the quantity of electricity produced by a unit of electromotive 
force, the volt, circulating in a conductor having the unit of 
resistance, the ohm, during the unit of time, the second. The 
current strength equals the electromotive force divided by the 
resistance. The watt is the unit of measurement of activity or 
power, and equals 0.735 foot-power per second. The number of 
watts used will equal the volts multiplied by the amperes. A 
one horse-power per second equals 746 watts. The kilowatt 
equals 1000 watts or 1.2 horse-power per second. The ampere 
is too large for medical measurements, hence it is subdivided a 
thousand times, each subdivision being a milliampere, and the 
strength of the current passing through the human body is 
measured by a milliamperemeter. 

The human skin is a poor conductor of electricity, unless 
the electrode is so moistened as to fill the air spaces in the 
epidermal layer with water. The resistance of a dry layer of 
skin may be several thousand ohms, but this resistance is 
reduced by moistening the skin to two hundred ohms or less. 
Often when the pain is greatest on the application of the galvanic, 
constant, current, but little electricity is passing, the pain being 
caused by the minute sparks penetrating the skin to the tissues 
beneath. After the current has passed for a short time through 
a moistened electrode the resistance seems to be overcome and 
the current passes more readily. This is quite probably 
because the tissues beneath the skin become hyperemic and 
therefore better conductors. The larger the electrode used, 
the less the pain, and with large electrodes, after the first 
contraction caused by the closure of the constant current, there 
is practically no sensation until the current is broken, con- 
sequently large electrodes should be used when it is desired to 
use a strong current. Generally the stationary electrode should 
be large, while the electrode that is used for treatment and 



640 THE PRINCIPLES OF THERAPEUTICS 

moved over different parts of the body should be small. If 
the deeper structures of the body are to be treated, both 
electrodes should be large, as tending to cause less pain. But 
the electrolytic and metabolic activity is just as active whether 
pain is felt or not. 

The surface of the body is hypersensitive to electrical appli- 
cations at the junctures of the mucous membrane with the 
skin and where the skin is close to bones. The parts where 
the skin is thin are also very sensitive to electrical applications, 
such as the inner surfaces of the arms and legs, and the fingers. 
Individuals vary greatly as to their susceptibility to electrical 
currents, depending on the thickness of the skin, and the 
nervous irritability. Some diseases increase and others dimin- 
ish the susceptibility to electricity. On the mucous surfaces 
the electrodes do not require to be moistened. 

In using the constant current, shock to the patient should 
always be avoided; consequently the current controller should 
be at zero when the electrodes are applied to the body, and 
then the switch slowly moved to the strength desired, to be 
again returned to zero before the electrodes are removed. 
Such management prevents pain and shock, and is the method 
used when it is desired to cause a general effect rather than 
stimulation of nerves and muscles. 

Galvanism. — The galvanic, or constant, current is perhaps 
the one of most importance in treating the general system by 
electricity. The current enters the body at the positive pole 
or anode, and makes its exit at the negative pole or cathode. 
The most pain is caused by the cathode as it is excitant, while 
the anode is mildly sedative, and at this pole the skin may 
become blanched. If the current of electricity is not broken, 
i.e., if the active electrode (the electrode which is moved 
about over the body) is not removed from the surface of the 
body, contraction of the muscles does not occur and pain is not 
caused, provided the electrode is properly moistened and 
applied with the proper amount of pressure, so that the skin 
becomes a good conductor and the tissues beneath alone are 
affected. Considerable strength of current may be tolerated 
if the electrodes remain stationary. As previously cautioned, 



ELECTRICITY 64 1 

before the electrodes are applied and before they are removed, 
the current controller should be placed at zero. This treatment 
of gradually increasing and gradually reducing the current is 
sometimes quite sedative to painful nerves, provided there is 
no inflammation. 

If the electrodes are stationary, polarization will occur 
(termed electro tonus) , namely, at the anode for a short distance 
in the direction of the cathode the nerves will be depressed 
(termed anelectrotonus) ; while at the cathode for a short 
distance toward the anode the nerve is made more irritable 
and excitable (termed katelectro tonus) . With the positive 
electrode stationary at an indifferent position, with the active 
electrode, the negative (the cathode), small and placed at the 
motor point of a muscle, when the current is closed the contrac- 
tion should be greater than when the poles are reversed, i.e., 
when the electrodes are reversed, the negative being made 
indifferent and the positive active. When the current is 
broken with the cathode at the motor point the opening con- 
traction of the muscle, i.e., when the current is turned off, should 
be less than when the current is broken with the positive pole 
or electrode at the motor point. When the negative pole 
(electrode) is at the motor point of a muscle, and the positive 
pole is on the back, the current is said to be descending. When 
the positive pole is at the motor point, and the negative pole 
is on the back, the current is said to be ascending. 

When the cathode closing contraction (a descending current) is 
greater than the anode closing contraction (an ascending cur- 
rent) and the anode opening contraction (an ascending current) 
is greater than the cathode opening contraction (a descend- 
ing current), the reaction of a muscle is normal. When 
these reactions become equal in intensity degeneration of 
the muscle has begun. When these reactions are reversed it 
is termed the "reaction of degeneration," and the muscle has 
degenerated. 

To excite a muscle the current is interrupted by removing and 
re-applying the electrode, by a spring "make and break" contact 
on the electrode handle, or by a current interrupter on the elec- 
trical apparatus. These interruptions may be made from a few 



642 THE PRINCIPLES OF THERAPEUTICS 

to several hundred times a minute. If the interruption is too 
rapid, the muscle takes no note of it and will not react. 

When nutritional effect is desired the current should not be 
interrupted. The patient may sit with his feet on a large moist 
electrode, or they may be on a metal electrode in a foot bath, or 
he may sit on a large moist electrode or lie on such an electrode. 
In any case the other active electrode is moved over the body, 
but kept in contact with it. 

To affect the nervous system a large electrode is placed over 
the upper abdomen in the region of the solar plexus, and the 
other pole is moved up and down the spine. Sometimes such 
treatments profoundly affect the circulation and quiet the nerv- 
ous system. 

The galvanic current may be applied to the head, and when 
the current goes through the. nerves of the lower part of the face 
the mouth will taste metallic. The positive pole applied to 
the tongue gives an acid flavor, and the negative pole an alkaline 
taste. When the current is applied near the eyes, sometimes 
luminous flashes will appear, especially if the patient is in a 
dark room. 

The galvanic current has sometimes been used for cerebral 
disturbances, but there seems to be no good excuse for such use. 
This current has been advised for stimulation of the phrenic 
nerve with both electrodes in the neck over the region of the 
nerve, or one on one side of the neck and one on the other; or one 
electrode over the region of the insertion of the diaphragm and 
the other at the phrenic nerve, for stimulation of diaphragmatic 
activity when respiration has stopped. While experimentally 
contractions of the diaphragm can be thus caused, clinically it 
is difficult not to also affect the vagus nerve and slow the heart. 

This constant current will cause reaction of paralyzed mus- 
cles when the faradic current has ceased to cause such reaction. 
But it should be emphasized that the galvanic current may do 
harm as well as good, and it is more potent for harm than is the 
faradic, interrupted, current. When it is used too strong, or 
an electrode remains too long at one location burning may be 
caused, perhaps serious burning. It should not be used on 
nerves or muscles that are inflamed. It is often of value on pain- 



ELECTRICITY 643 

f ul joints and it may cause absorption of exudates ; but for these 
purposes electricity is not much used by the majority of practi- 
tioners. When a muscle is fatigued it may be restored by pass- 
ing the constant current through it for several minutes and 
then causing the muscle to contract several times either by 
interrupting this current, or, better, by the faradic current. 

Electricity must not be used on muscles paralyzed by a cen- 
tral lesion, as an apoplexy, until at least six weeks after the 
injury occurred. Also after paralysis from an acute inflamma- 
tion, as anterior poliomyelitis, electricity must not be used for 
some weeks after all active symptoms have ceased. 

Cataphoresis. — Cataphoresis has been the name applied to 
the absorption of substances through the skin caused by the ac- 
tion of the constant current. This effect is due to the electro- 
lytic action of the current and is termed ionization. Anions 
are substances which are attracted to the anode and repelled 
by the cathode. They are termed electronegative. Cathions 
are substances which are attracted by the cathode and repelled 
by the anode. They are termed electropositive. Metals, bases 
and alkaloids are electropositive, i.e., are attracted to the cath- 
ode or negative pole. Acid substances are electronegative, and 
collect at the anode or positive pole. Therefore to obtain 
absorption of a substance by electricity the electrode must be 
moistened with a solution of this substance, and it will be elec- 
trolyzed and more or less absorbed into the tissues. An alka- 
loid for instance, as morphine or cocaine, will be driven into the 
tissues at the positive pole. Metals and alkalies should be 
placed on the positive pole, while acid substances should be 
placed on the negative pole. 

This method is not much used except by some few physicians. 
Electrolytic baths are sometimes given in which some drug is 
dissolved in the bath, but there is no real necessity for such 
treatment. It has been used in gout and rheumatism. Metal- 
lic electrolysis is sometimes done by using copper electrodes to 
cauterize the mucous membrane of the nose and mouth, on 
granular eye-lids, and in pelvic conditions. Such metallic 
electrolysis is also germicidal. 

Considerable counterirritation will be caused if the positive 



644 THE PRINCIPLES OF TEERAPEUTICS 

pole is moistened with chloroform; such treatment is often 
secondarily sedative to a painful nerve. Iodine has been driven 
into the tissues by this method, and the thyroid gland has 
been so treated. While a non-toxic simple goiter may be 
thus treated, electricity, whether galvanic, faradic, or sinusoidal, 
should not be used on or near the gland in hyperthyroidism. 

Electrolysis. — A chemical and electrolytic action of the 
constant current is frequently utilized for the destruction of 
tissue. For this purpose the electrodes are generally needle 
points, and at the positive pole the needle becomes imbedded 
firmly in the tissue, while at the negative pole bubbles of 
hydrogen gas form around the needle and it is loose in the 
tissues. The reaction of the tissues around the negative 
needle is alkaline similar to the destructiom of tissue by a 
strong alkali. Around the positive needle the reaction is 
acid, similar to necrosis caused by an acid. The cauterized 
tissue at the negative pole will be discharged more or less 
rapidly, while the dry eschar at the positive pole will become 
loosened slowly. It has been estimated that about 200 milli- 
amperes of current will destroy tissue at the negative pole the 
length to which the needle is inserted and a quarter of an inch 
in diameter in two minutes. To withdraw the positive needle, 
it must either be cut down upon, or the current must be momen- 
tarily reversed. The structure of the positive needle should 
be of platinum, gold, or carbon, so that it will not corrode 
and become tightly fixed in the tissues. Coagulation will be 
caused and bleeding stopped at the positive pole. This 
kind of treatment is very different from a local destruction 
of tissue by the electrocautery or by the high frequency 
cautery. Electrolysis is now rarely used, as the roentgen ray 
and radium have made its use unnecessary. 

Faradism. — This is the interrupted current of electricity, or 
the induced current as it is called. The primary or the second- 
ary current may be used, the secondary current often being the 
gentler of the two. The sound of the interrupter must be 
clean, not grating; it should be a musical hum. The volume of 
electricity entering the patient from this current is very small, 
and its chief use is to cause contractions of muscles (thus 



ELECTRICITY 645 

increasing the circulation of the blood and lymph) and improve 
their nutrition. 

It is not very important which electrode is made active, al- 
though the cathode is perhaps a little more stimulating The 
strength of the current, which should be just sufficient to cause 
contractions of each muscle treated, may be varied by moving 
the iron core of the coil on the instrument. To act on the 
muscles the electrodes must be moistened as when using the 
constant current, and they should be firmly applied. The 
indifferent electrode should generally be large and the active 
electrode small. When it is desired just to stimulate the skin, 
a wire, or a silk wire, dry brush may be used. 

Strong currents may act through the abdominal walls to 
cause contractions of the stomach and intestines. However, 
more satisfactory results are obtained by passing an insulated 
electrode into the stomach, which should be previously filled 
with water, with the other electrode on the abdomen or back. 
To directly act on the intestines an insulated electrode is 
passed into the rectum after an injection of physiologic salt 
solution has been given. 

Faradization of the extremities, or of all the muscles of. the 
body, is a useful method of causing muscle exercise in invalids, 
especially when conjoined with massage. The current used 
should not be strong, but just sufficient to cause contractions of 
the muscles. The after effect is often sedative, on account of its 
causing a greater circulation of blood in the peripheral vessels 
and therefore a diminished amount in the brain. 

Muscle pains and some nerve pains are benefited by this 
current, provided there is no inflammation. Patients suffering 
from hysterical pain are benefited physically and psychically 
by faradism. 

It should be remembered that when any electrical current is 
applied to cause contractions of a muscle, the contractions will 
develop more rapidly and be stronger if the active electrode is 
applied to the motor point of the muscle. These motor points 
can be learned from diagrams in any book on nervous diseases. 

Sinusoidal Current. — The sinusoidal is a slow alternating 
(surging) current and the poles change so rapidly that there is 



646 THE PRINCIPLES OF THERAPEUTICS 

no difference in their effect. When the alternations occur with a 
frequency of about twenty times a second the muscle to which 
the current is applied will contract and relax, and the effect is 
clonic contractions. When the alternations are one thousand 
or more a second the muscle does not relax but goes into a te- 
tanic condition and the contraction or spasm does not relax but 
is sustained. This tetanic contraction reaches its greatest 
intensity when the alternations are about 2500 a second. When 
the alternations reach as many as 5000 a second the muscle begins 
to relax, and above 10,000 alternations a second contraction is 
not caused but metabolic changes occur in the muscle by im- 
pulses received at this frequency. The so-called "high fre- 
quency current" of 100,000 alternations per second may not 
cause motor activity or even sensation, but the metabolism is 
increased. Even with a very high voltage (sufficient to cause 
death if the frequency of the alternations were reduced) this 
current will traverse the body without harm. 

The sinusoidal current is very useful in treating weakened 
and paralyzed muscles, and seems to be just as efficient and 
causes less pain than the faradic current. 

High Frequency Currents. — (d' Arsonval). — The so-called 
d 'Arsonval current is a high frequency current of low voltage 
and high amperage. The Tesla current (sometimes called the 
violet ray; vacuum electrodes) is a high frequency current of 
high voltage and low amperage. The so-called Oudin current 
is a high frequency current of a higher voltage than the d 'Arson- 
val but not as high voltage as the Tesla, and a lower amperage 
than the d 'Arsonval but not as low amperage as the Tesla. 
The violet ray is a high frequency current in a vacuum electrode. 
High frequency currents with the Oudin resonator give a 
current of high potential, and when to the high frequency 
current is added a secondary coil we have what is termed the 
Tesla transformer. 

The rapidly alternating induced current was first shown to 
have physiologic activity by d 'Arsonval, although Morton had 
previously discovered these high frequency currents. These 
currents are used to reduce blood-pressure when it is high, but 
when used too long may cause shock and depression which may 



ELECTRICITY 647 

last for some hours. It generally causes a lowering of the blood- 
pressure, but there is frequently no lasting benefit from the 
application. However, this form of electricity does increase the 
output of urea and other products of metabolism, and therefore 
has been advised for chronic arthritis, gout, myalgias, and 
neuritis. 

For this treatment the patient is placed on an insulated couch 
or insulated chair, which is connected with one electrode. The 
other electrode consists of a metal handle, which should be 
grasped by both hands. At first the duration of the treatment 
should not be more than five or ten minutes, to note the effect 
on the patient. Subsequent treatments, if no unpleasant 
symptoms occur, should last from fifteen to twenty minutes. 
From 900 to 1200 milliamperes, the amperage being gradually 
increased and then gradually diminished, is the dosage generally 
advised. However, a much smaller dosage of from 600 to 700 
milliamperes seems frequently to be of as much value. The 
patient should freely perspire after such treatment; the dosage 
and the duration of the treatment depend upon the amount of 
perspiration caused. At first daily treatments seem advisable, 
and later less frequent treatments, depending entirely upon the 
results and upon the condition for which the treatment is given. 

The vacuum high frequency electrodes are used satisfactorily 
for nerve, muscle and joint pains. Sometimes this treatment 
is immediately successful. It should not be used when there is 
inflammation of the part. If the patient is insulated on a stool 
or couch, the vacuum electrode held stationary upon a part will 
cause a certain amount of diathermic heat. 

Diathermy. — Diathermy is a term applied to electrical in- 
ternal heat caused by the d' Arson val current. The electrodes 
are applied so that the mid-point between them will be the 
organ or part it is desired to heat, as the greatest heat occurs 
in the mid-distance between the two electrodes. The electrodes 
used are metallic disks of varying sizes or sheet lead plates 
which may be moulded to the part, or large felt electrodes, 
which must be moistened, may be used. Sometimes the 
patient is placed on an insulated couch and the other electrode 
applied over the part to be treated. When the metal elec- 



648 THE PRINCIPLES OF THERAPEUTICS 

trodes are used the skin should be moistened and the electrode 
firmly held or fastened to the body. Or a lather may be made 
with ordinary shaving soap and spread over the part and the 
electrode applied over this. If the electrodes tip and do not 
hit all points of the skin equally, sparks develop and pain is 
caused. The greatest of care should be exercised to never 
apply the electrode or remove it until the current has been 
switched off. Also the cords must be so placed that they do not 
come in contact with any part of the body. The amperage 
and the duration of the treatment depends entirely upon the 
sensation of the patient. The amperage should be sufficient to 
cause distinct heat, and the duration is generally short, depend- 
ing much upon the sensation of the patient. It is a mistake to 
increase the amperage too rapidly. 

This treatment is in its infancy, but it seems to be very 
successful in causing hyperemia and therefore in promoting 
recovery of diseased or disturbed tissue. This heat is also 
very efficient in quieting nerve pains and in treating neuritis 
of all forms. It has also been used with large pad electrodes to 
treat disturbances of the abdomen and disease of the lungs. 

Static Electricity. — The static, or Franklinic, current is 
evolved by a frictional machine. The impression this instru- 
ment makes on the mind must always be taken into consider- 
ation in any favorable results that may be obtained, though 
there is no question of its positive activities. 

Stimulation of muscles and nerves may be given by what is 
termed the static spark, by a pointed electrode; or the patient 
may be subjected to what is termed the static breeze, by a bell 
electrode suspended over the insulated patient. Also friction 
of the muscles may be given by means of a roller electrode. 
At the point where the spark discharges, the skin will be at first 
pale, or there will be a goose-flesh appearance, and later there 
may be a swelling like an urticaria. Some burning may be 
caused if the spark is used too strong, or the skin is very tender. 
The clothing of the patient need not be removed, and the 
sparks penetrate woolen especially well. 

The violet ray may be directed toward the uncovered skin 
for a sedative effect on nerves, or it may be applied with the 



ELECTRICITY 649 

frictional method but through clothing for counterirritant 
effect. Sometimes the spark of the frictional current is very 
successful in causing benefit in joint, nerve and muscle pains. 

Static electricity has been used for all kinds of neuroses 
as well as for neuritis, rheumatism, and gout. There is no 
question that besides the local effect caused, the circulation is 
many times improved, the metabolism stimulated, and elimi- 
nation increased. Doubtless the same success may be caused 
by massage, hydrotherapeutic measures, and by other forms 
of electricity. 

Autocondensation has sometimes been termed the electro- 
static bath treatment, and it has been claimed if the insulated 
patient is connected with the positive pole he will be stimulated; 
if connected with the negative pole, he will be more or less 
quieted. High blood-pressure and some systemic disturbances 
have been treated by autocondensation. This treatment is 
given by insulating the patient and placing him in connection 
with the machine that furnishes static electricity and he 
becomes polarized, the blood-vessels dilate, and the blood- 
pressure falls. There is no sensation from this treatment. 
When first applied the patient should not remain insulated 
more than a few minutes, to ascertain whether or not much 
depression follows the treatment. Metabolism is increased 
though the benefit in high blood-pressure is not great from 
autocondensation. 

Roentgen Ray. — It is not purposed to more than note the 
enormous value of the roentgen ray in the diagnosis and proper 
treatment of many conditions. The effect, both local and 
general, of the x-ray is profound. Its ability to modify cells, 
glands and organs; its germicidal power; its action on blood- 
vessels, growths, and on the blood-forming organs, makes the 
study of roentgenology to-day a specialty in medicine. The 
necessity for roentgenograms of the bony structure of the 
body, of the chest, abdomen, and skull, makes every hospital 
and sanatorium imperfectly equipped unless it has apparatus for 
taking such pictures and for giving such therapeutic treat- 
ments as are necessary. Also the pictures taken and the 
treatment given must be by a skilled roentgenologist. Den- 



650 THE PRINCIPLES OF THERAPEUTICS 

tistry cannot be properly practised to-day without roentgeno- 
grams of the teeth treated, or to be treated, and for the detection 
of concealed infection. The value of barium pictures in 
gastrointestinal diagnosis is proved. It should be emphasized, 
however, that misinformation is worse than absence of infor- 
mation. Therefore, imperfect pictures or improper reading 
of perfect pictures furnish many regrettable instances in this 
art. One should never accept a picture or its reading from 
one who has not made a careful study of the subject. 

Radiotherapy. — The "soft tube" is used more especially for 
action on the skin or surface of the body; the "hard tube" is 
used for penetration. Blond skins seem more susceptible to 
the rays than dark skins, but the exact action on any particular 
individual must be noted by making the first treatment short 
and not giving the second treatment until enough time has 
elapsed to allow any undesirable reaction on the skin to become 
evident. X-ray burns must not be caused. The hair of the part 
treated will fall out, but it generally grows again. 

The art in the use of the roentgen ray has so advanced that 
the exact dosage can now be measured and accurately deter- 
mined. Even the quality and quantity of the rays can be 
measured. To give intensive treatment for deep-seated condi- 
tions the skin of the part must be protected, and various mate- 
rials are used for this purpose. Treatment so applied is termed 
filtered x-ray treatment and crossfire method. Very important 
is it in treating malignant growths to determine the lethal dose 
of the roentgen ray. Wood and Prime 1 have experimented on 
animals in whom sarcoma and cancer have been developed, and 
have come to the following conclusion: "That the amount of 
roentgen ray necessary to kill all the cells of a rapidly growing, 
very cellular, and highly malignant sarcoma or carcinoma in 
man is between 5 and 7 erythema doses of filtered roentgen ray 
when the tumor is on the surface of the body. Every centi- 
meter of tissue that covers the tumor makes an additional 
amount of roentgen ray necessary. " 

Testicular and ovarian activities are interfered with not only 
by action of the direct rays when the regions are not protected, 

1 Journal A. M. A., Jan. 31, 1920, p. 308. 



ELECTRICITY 6$I 

but also by the action of this potent force in the vicinity of the 
x-ray activity, namely, when the individual is unprotected in 
the raying room. The male so exposed may become sterile, 
and the female ceases to menstruate, and hence probably ovula- 
tion, at least temporarily, ceases. It has also been shown that 
serious systemic symptoms may occur from applications of the 
x-ray without the occurrence of x-ray burns; metabolism may 
be seriously interfered with, there may be a breaking down of 
body protein, and anemia may occur. Consequently, this 
potent force must always be administered with great care, and 
utilized only by one who has exhaustively studied the subject. 

There is a difference of opinion as to the value of the x-ray 
treatment of enlarged thyroid glands and tuberculous glands, 
some clinicians claiming that it is always efficient in such cases, 
others claiming that it is disappointing. On the other hand, 
the x-ray treatment of an enlarged thymus gland seems to be very 
successful. In some blood diseases, as leukemia, great success 
has been obtained in reducing the size of the enlarged spleen 
and in diminishing the excess of white corpuscles by raying the 
spleen and the long bones respectively. The roentgen ray is 
also frequently used in the treatment of certain skin diseases. 

Whether the skin, or whether deep-seated organs are to be 
treated, the dosage must be carefully estimated, lest burning 
and destruction of tissue be caused. As the x-rays go in straight 
lines, protection of tissues which it is not desired to radiate may 
easily be given. Some reaction, denoted by reddening of the 
skin, must be caused to give much local effect, but only the 
expert can determine the border-line between sufficient and not 
sufficient dosage. 

The value of the roentgen ray in reducing the size of uterine 
fibroids and in stopping profuse menstruation and metrorrhagia 
seems to have been thoroughly demonstrated. Unless it is 
positively necessary to surgically remove fibroid and muscle 
tumors of the uterus the roentgen ray treatment is indicated. 
After one or more treatments properly directed and of proper 
strength amenorrhea generally occurs, and during this period 
the tumor frequently becomes smaller in size. When ovula- 
tion and menstruation again begin the tumor may again grow, and 



6^2 THE PRINCIPLES OF THERAPEUTICS 



the proper treatment must be then decided upon by the gyne- 
cologist and the roentgenologist. During this artificial meno- 
pause the patient is likely to suffer from the symptoms of that 
condition, namely, hot flashes, sweatings, and possibly more or 
less nervousness and sleeplessness. Which ovarian and pelvic 
conditions should be treated by the roentegn ray must be de- 
termined later. Cancer of the body of the uterus at the present 
time seems best treated by complete surgical removal. Wheth- 
er inoperable cancer is best treated by the roentgen ray or by 
radium, statistics must later determine. At the present time 
the treatment of cancer of the cervix with radium seems to be 
as satisfactory as by radical surgical measures. 

Radio-active Substances. — The number of radio-active 
substances is very large, and most natural waters are radio- 
active. Many so-called medicinal springs owe part, at least, of 
their curative properties to the fact that they contain radio- 
active substances and dispense radium emanations. Bottled, 
or shaken, waters lose this peculiar substance, and become less 
efficient as therapeutic agents, hence a sojourn at these springs 
is often essential for the best results. Rooms are constructed 
at the springs in which patients may sit or recline and inhale the 
emanations from the spring water. Or deep bathtubs are con- 
structed for patients to He in the water and inhale the emana- 
tions which are retained in the upper part of the tub. 

Radio-active substances on breaking up and forming other 
combinations furnish heat and marked chemical activity, and, 
forming other combinations, rays occur called alpha, beta, and 
gamma. The alpha (helium) rays (about 90 per cent, of the total 
rays) cannot penetrate the skin, but when taken internally are 
very active. These chemical combinations may be stored in 
the body, gradually furnish stimulation, promote metabolism, 
and may be excreted in various ways. Electrical irritation may 
be caused by the breaking up of radio-active molecules. 

Small doses of radio-active stuff have no action in the human 
body; medium doses certainly stimulate all cellular activities; 
while large doses may cause cellular breakdown of some tissues 
while other tissues may be only stimulated. It should be under- 
stood that all human tissue is more or less radio-active, some 



RADIO-ACTIVE SUBSTANCES 653 

individuals more than others, some tissues more than others, 
and perhaps some pathologic tissues more than others. 

The radium treatment of disease is mostly given by inhala- 
tions, by baths, by drinking of the water, and by the application 
of mud wet with radio-active solutions, or mud made of radio- 
active earth. 

The springs vary so greatly in radium activity that they must 
be classified, and the following has been adopted: 

(1) Those that contain 50 or less mache units a liter (quart). 

(2) Those that contain from 50 to 100 mache units a liter. 

(3) Those that contain more than ioo mache units a liter. 

The beginning dose internally should be small and daily in- 
creased to 5,000 or more mache units. The radium water is 
best taken after meals, and too large doses may do harm. Hypo- 
dermic medication has been urged, but this has not yet been 
well developed. Inhalations are only well carried out at the 
springs. Under active treatment or by inhalation there may 
be some rise of temperature for a short time, with, later, a low- 
ering of temperature, and the uric acid output may be increased. 
The blood production may be stimulated, or in over-doses inhib- 
ited, or the red corpuscles may even be destroyed. The leuco- 
cytes may be increased, or, with large doses, many may be 
destroyed. The blood-pressure is lowered. 

From these activities of radio-active substances it is evident 
that they might be of value in conditions of high pressure, in 
gout, in rheumatism, in some blood disturbances, and in some 
cachexias. They would not be advisable in low blood-pressure, 
in profound disturbances of the heart or of the blood, or in 
general prostration. 

The use of radio-active substances for general conditions is 
on the increase, but part of the success of such treatment is 
doubtless psychic, on account of the obscure action of this 
expensive, mysterious matter. Very weak preparations are 
probably no more active than ordinary substances, water or 
earth, with which the individual comes in daily contact, conse- 
quently the salts used to impregnate water for medicinal 
purposes should probably furnish not less than 5,000 mache 



654 THE PRINCIPLES OF THERAPEUTICS 

units. However, of the dosage we are not sure, and it is always 
well to begin with a small dose, which may be rapidly increased 
to 5,000 mache units. The 1920 issue of 'New and Non-official 
Remedies" recognizes radium bromide, carbonate, chloride, and 
sulphate, all of which are more or less mixed with barium. 
Radium outfits for therapeutic use may be obtained. 

For home treatment thorium X is generally used to impreg- 
nate water for drinking. Uranium X has been thought to 
furnish more of the beta ray effect, while the thorium X fur- 
nishes mostly the alpha ray. Uranium and its salts when taken 
internally have been shown to be serious irritants to the kidneys. 

Radium. — Roentgen discovered the x-rays in 1895; Bec- 
queral discovered the uranium rays in 1896; and Madam Curie 
discovered the new element radium in 1898. 

According to Moore, 1 Chief Chemist of the United States 
Bureau of Mines, though at the present time more than 100 
grams of radium have been produced, there is not by any means 
100 grams available to-day, and in this country there is prob- 
ably not more than from 20 to 25 grams. An atom of radium 
will disburse radiations for many thousand years. The alpha 
rays of radium do not penetrate tissues and are easily stopped; 
the beta rays have slight penetration; and the gamma rays 
have high penetration like the roentgen rays. While the alpha 
rays may be of value when given internally, it is the beta and 
gamma rays that act externally and penetrate tissue. 

Stratton, 2 Director of the Bureau of Standards, states 
that the radium certificate issued by the National Bureau of 
Standards does not contain a statement of the actual amount of 
radium contained in the preparation, but merely a statement 
of its equivalent radium content. 

The value of radium in the treatment of malignant growths 
must depend largely upon the dosage; it must be enough and 
not too much. Boggs 3 states that the dose of radium that 
causes erythema may not be the dose necessary to kill cancer 
tissue. Inefficient treatment may lead to a fatal ending in 

1 Journal A. M. A., April 17, 1920, p. 1115. 

2 Journal A. M. A., June 19, 1920, p. 1731- 

3 New York Med. Journ., June 12, 1920, p. 1013. 



RADIUM 655 

what might be a favorable case. He urges the necessity of not 
only sufficiently treating the growth itself, but also the surround- 
ing edges must be properly treated to prevent metastasis. This 
is true with post-operative roentgen ray treatment as well as with 
post-operative radium treatment. Boggs quotes William Mayo 
as stating that in pre-operative radiotherapy of cancer tissue 
either with radium or with x-ray, that the operation should not 
be too long delayed after the treatment, as when the activity of 
the tissues has been decreased, it may soon again become in- 
creased, and the value of the pre-operative treatment be 
lost. Mayo also stated that "radiotherapy destroys cells for 
a certain distance, but cells are sterilized at a greater distance 
so that their reproduction is checked, and connective tissue 
is caused to develop which acts as a barrier to the further 
extension of the malignant process." Boggs states that it 
seems proved that radium can destroy cancer cells beyond the 
reach of the knife, and "that even in operable cases of cancer 
of the cervix metastasis has taken place in the pelvic lymphatics 
in thirty to forty per cent, at the time of the operation." 
He believes that when radium is used before operation on 
surgical cases hysterectomy should be performed within four to 
eight weeks, before marked fibrous formation has taken place. 
Some gynecologists believe that the radium treatment, when 
properly carried out, of cancer of the cervix gives a more 
favorable prognosis than operative treatment. Some im- 
provement is always caused by radium treatment, even when 
the case is an advanced one. 

It would seem from statistics reported that beginning cases 
of carcinoma of the cervix may be treated by radium; 
that probably at the present time beginning cases of carcinoma 
of the fundus should be surgically removed with later roentgen 
ray or radium treatment. 

Radium has also been used for the treatment of uterine 
fibroids and especially when they cause hemorrhage. Whether 
this treatment is better than the x-ray treatment must be 
determined by later statistics. The roentgen ray being much 
more available than radium, it will probally be a long time 
before that treatment is supplemented by radium treatment 



656 THE PRINCIPLES OF THERAPEUTICS 

in non-malignant growths. The radium rays do not penetrate 
as deeply as do the roentgen rays, therefore radium is used 
more successfully for surface conditions and tumors that can 
be reached, as in the larynx or in the uterus. Tubes containing 
radium are sometimes imbedded in the tumor growth so that 
it will act throughout the tissues of the tumor. As with the 
roentgen ray, too small a dose may stimulate growth, while a 
larger dose will destroy the pathogenic tissue. 

When the radium treatment is energetically given, especially 
to the uterus, it must be understood, as pointed out by Graves, 1 
that very unpleasant symptoms may occur. There may be 
nausea, bleeding, severe pain, and much other general nervous 
disturbance. Consequently, a patient must be under special 
supervision in a hospital when this active treatment is given. 
Later there may be much leucorrhea follow the treatment. 

The radium treatment of epithelioma and other growths 0.1 
the skin, especially those of the horny variety, has been success- 
ful. Cohen and Levin 2 sum up their radium treatment of 
cataract by stating that it is harmless to the eye, that it dimin- 
ishes opacities of the lens, that it does not interfere with later 
removal of the complete cataract, and they believe that begin- 
ning cataract should be treated by this method. 

It is hardly necessary to insist that all treatments with 

radium for the destruction of tissue or for action on the skin 

and mucous membranes should be undertaken only by an 

expert. 

HYDROTHERAPY 

Baths and applications of water were ancient methods of 
preserving health and of treating disease, as the writings of 
Hippocrates testify, even cold water bathing for fever being 
recommended by him. Galen and early Roman physicians used 
water as a therapeutic measure, but the medical school at 
Salernum was the only recorded advocate of water treatments 
during the Middle Ages. Some revival of the use of water 
therapeutically occurred in the seventeenth and eighteenth cen- 
turies, especially in England and Germany, but not much gen- 

1 New York Medical Journal, June 5, 1920, p. 969. 

2 Journal A. M. A., Oct. 18, 1919, p. 1193. 



HYDE OTHER APY 657 

eral interest in this physical treatment developed until, in 1820, 
Vincent Priesnitz, a farmer of Silesia, began to laud its use for 
diseased conditions. Professor William Winternitz, of Vienna, 
has been termed the father of modern hydrotherapy, as he raised 
this method of treatment to a more scientific basis. Simon 
Baruch, of New York is the pioneer in this country in urging the 
great value of this physical means of treating disease. 

In Germany, in the last decade of the last century, a Roman 
priest named Kneipp taught and expounded the value of cold 
water for all kinds of diseased conditions, and advised both 
adults and children to walk bare-footed in cold water, or in snow, 
to prevent disease. This obsession has been copied in various 
parts of America, both by peculiar cults and by radical special- 
ists in tuberculosis. Kneipp died in 1903. 

By hydrotherapy is generally understood the treatment of 
the whole body by various types of water baths. However, 
under this heading it has become the custom to describe the 
applications of hot and cold water, by various methods, to a part 
of the body for local action on that part. Obviously the phys- 
iologic changes occurring from a treatment of the whole body 
must be different from those that occur when only a small por- 
tion of the body is treated. Also, the therapeutic object aimed 
at in the two instances must be different. Hence the subject 
of hydrotherapy must be discussed under separate headings. 

Balneotherapy. — The effect of baths on the body is shown by 
the effect on the organs and the circulation when heat or cold is 
applied to the surface of the body. If the body is warmed all 
over, the surface vessels dilate, the blood-pressure is lowered, 
and internal congestion is relieved, i.e., the internal organs will 
be depleted of blood. By hot baths the surface of the body is 
warmed; the skin is better nourished; peripheral nutrition is 
improved; nerve rest is caused, perhaps sleep; the kidneys be- 
come more active, if the blood-pressure is not too much lowered; 
and the circulation of the lymph and blood in the muscles is 
promoted. If the bath is too hot or too long continued anemia 
of the brain is caused, and faintness. 

The reverse of all this occurs from cold baths, namely, the 
peripheral blood-vessels contract; the internal organs and the 

42 



658 THE PRINCIPLES OF THERAPEUTICS 

brain are congested; the blood-pressure is raised; the kidneys 
are stimulated; intestinal peristalsis is increased; and general 
metabolism is more or less increased. If the cold bath is too 
intense or too long continued there will occur general depression 
and impairment of function. The number of corpuscles in the 
peripheral blood, both red and white, may be greatly modified 
by the action of hot and cold baths. 

It is therefore evident that by hydrotherapeutic measures we 
can actively modify the circulation and at times the nutrition of 
all parts of the body. Therefore, these measures when properly 
directed are potent for good, and when misdirected may do 
harm. 

Heat for Systemic Effect. — Theoretically, the hot bath should 
not be taken except at bedtime, on account of the relaxation caused 
and the tendency to produce anemia of the brain and therefore 
sleep. At other times of day, theoretically, a hot bath should 
be followed by a cold plunge or cold sponge to again raise the 
blood-pressure and prevent the feeling of relaxation. However, 
it is possible that standing in the bathroom while the individual 
is drying his skin (if the bathroom is not too warm) may, by the 
effect of the cool air, again raise the blood-pressure. The corol- 
lary of this is obvious, namely, that too hot baths should not 
be taken; that too frequent hot, or even warm, baths should not 
be allowed; and that the individual should not remain too long in 
a warm or hot bath. Young girls and young women are espe- 
cially prone to soaking in hot baths, which causes loss of 
strength and general debility. The reverse of this is also true, 
namely, that a patient with high tension, high blood-pressure, 
and a cool and dry skin is especially benefited by hot baths. 

The warm bath, i.e., a heat but a degree or so more than the 
body temperature, is sedative. Primarily a hot bath causes 
some nervous stimulation and may cause temporary irritability 
of the nervous system, especially if the heat is sufficient to cause 
a momentary vaso-constriction of the peripheral vessels. As 
soon as the patient comes out of such a hot bath, especially if he 
has drunk much water, perspiration will be profuse. This pri- 
mary peripheral vaso-constriction from a too hot bath may 
cause a feeling of fullness in the head, which is soon, however, 



HYDROTHERAPY 659 

relieved by the secondary vaso-dilation that occurs. At this 
time there may be a feeling of faintness. The hot bath will in- 
crease the internal temperature, although the temperature may 
fall later by the profuse perspiration. The perspiration follow- 
ing such a hot bath will cause a large loss of water from the body, 
and, if the system is not replenished with water, may cause a 
concentrated urine and constipation. A considerable amount 
of sodium chloride may also be thus lost through the skin. In 
hot weather a hot bath is a great relief, as when the individual 
comes out of the bath, on account of the perspiration and evapo- 
ration, he feels much cooler and his temperature is reduced. 
Also it may be noted that in some countries, notably Japan, the 
hot bath is in daily use, and those who are used to them are 
not depressed. This is especially true if too warm clothing is 
not put on after the bath. 

A hot bath, not a warm bath, tends to relieve not only 
internal congestion, but relaxes spasm and contraction of 
muscular tubes and relieves muscle cramps. Therefore hot 
baths are resorted to in the various abdominal colics. Warm 
baths are sedative in nervous excitement and may be used in 
chorea and mental excitement. 

Hot baths increase metabolism, and if they are taken too 
frequently, increase tissue waste, and weight may be lost, 
consequently various forms of hot baths are used to promote 
loss of weight in the obese. 

When there is low blood-pressure, or when there is edema of 
the legs or general anasarca, hot or warm baths are not indi- 
cated; they will do harm. In any serious condition hot baths 
are not indicated, unless there is high blood-pressure, and then 
the water should not be warm enough to cause nervous stimu- 
lation. In depressed circulation, but with the blood-pressure 
not very low, warm baths, or the medium bath (a bath just 
above the body temperature) are beneficial as they increase 
the peripheral circulation and relieve the internal congestions. 

In inflammations of the skin hydro therapeutic measures may 
be contraindicated, but various demulcent additions may be 
made to the bath, especially if there is a tendency to irritation 
or urticaria after bathing. Bran is often added to baths for 



660 THE PRINCIPLES OF THERAPEUTICS 

such purposes. Ointments or fats are sometimes rubbed on the 
irritated skin before the bath is taken. 

It should be emphasized that uremia is not benefited by 
hydrotherapeutic measures that cause profuse general sweating. 
It should be remembered that only water, sodium chloride, and 
a few other salts, and very little urea, are excreted by even 
profuse perspiration, and the abstraction of water concentrates 
the poisons circulating in the blood. Therefore, while a 
patient may survive such treatment, on account of blood being 
drawn to the periphery and the kidney congestion being thus 
relieved they may become able to resume excretion, still the 
same results may be caused by hot packs to the lumbar region 
without recourse to such profuse perspirations as endanger the 
life of the patient. To repeat, it is illogical to concentrate 
poison in the individual's blood by profuse sweating. Vene- 
section had better be done in these instances, provided the 
blood-pressure is high. If the blood-pressure is low in advanced 
cardio-vascular-renal disease, profuse sweating and active 
purgation are positively contraindicated. 

The toxins of infection and the salts of metallic poisons 
may, by various forms of hot baths, be brought from the 
internal organs to the peripheral and general circulation and 
their elimination made more rapid. 

Hot applications to the abdomen may be of advantage in 
relieving cerebral congestion. 

Turkish Baths.— The so-called Turkish bath is given by a 
sojourn of the individual in a series of rooms, with the temper- 
ature gradually increasing, even up to 150 F. 

The bather, deprived of all clothing, enters the first room 
in which a turban saturated with cold water should be placed 
about his head. As soon as he becomes accustomed to the heat 
of this room he proceeds to the next, and so on, remaining in 
each room until he does not mind the heat. Ordinarily he 
should drink several glasses of cold water to aid in promoting 
perspiration. A feeling of faintness, dyspnea, or of oppression 
in the chest should cause the bather to immediately go to a 
cooler room, and a patient should not go into the rooms of high 
temperatures unless by the advice of a physician. After the 



HYDROTHERAPY 66 1 

bather has completed a circuit of rooms, he should be massaged 
(though this is not essential) and he then should take a cold 
shower bath; some patients take a cold plunge. This reaction- 
ary treatment with cold water should always be a part of the 
Turkish bath. After the shower, the patient should lie down 
for at least two hours. 

During this bath the individual loses more or less water by 
perspiration, the amount depending upon his condition. The 
water lost may vary from 500 to 1,000 grams. 

This bath is valuable in rheumatic and gouty conditions; 
in obesity; in insufficiency of the kidneys, provided the circu- 
lation is good ; in high blood-pressure when there is not too much 
plethora and the arteries are not seriously sclerosed. It is also 
valuable in chronic malarial conditions, after prolonged treat- 
ment with mercury, and in chronic lead poisoning. Patients 
who are weak should not take a Turkish bath. 

A sweat bath, somewhat similar to the Turkish bath, may be 
improvised by having the patient sit under a rubber tent, with 
an alcohol lamp under the chair or somewhere in the tent with 
him. Or, he may be surrounded by blankets, when a rubber 
tent is not at hand. In either case, his head is in the outside 
atmosphere; he is in the cabinet from his neck down. Or, the 
patient may be in bed and warmly covered with blankets, and 
the heat from an alcohol lamp be directed by a pipe under the 
bed clothes. The patient is given several glasses of water, 
after he has become well heated, and the effect is a sweat, after 
which he may have massage, and then take a cold shower or a 
cold sponge as seems advisable. 

Russian Baths. — The Russian bath is a vapor bath, the room 
being saturated with steam. The bather proceeds from one 
room to another as in the Turkish bath, his head being pro- 
tected, as before, with a wet towel. This bath is more prostrat- 
ing, and the individual is more likely to suffer heat exhaustion 
than in the Turkish bath. This bath is not often advised by 
medical men. 

The Russian bath may be partially duplicated in the patient 's 
home, either under a tent, or in bed, as described for the Turk- 
ish bath, the only difference being that water is boiled in the 



662 THE PRINCIPLES OF THERAPEUTICS 

tent with the patient, or steam from boiling water is directed 
under the bed clothes by means of a pipe. 

Electric Light Baths.— The electric light cabinet treatment, 
or the electric cradle for bed treatment, is now very much in 
vogue. It is simpler, the effect is generally satisfactory, and 
the prostration is not so great as when the Turkish bath or 
body baking treatments are given. Massage, a cold shower or 
cold plunge, and subsequent rest are essential in this treatment. 
The objects for which the cabinet baths are used are much the 
same as for Turkish baths, but they are especially valuable, 
not pushed to the point of much perspiration, in quieting pe- 
ripheral nerve pains. Acute colds may be aborted by the Turk- 
ish bath, by the electric cabinet bath, or by a body bake. Also 
when menstruation stops suddenly from exposure it may be 
again started by such treatment. 

Cabinets for Body Baking. — These cabinets or heating 
apparatus can be well operated only in hospitals or sanatoria. 
They have been largely supplanted by the electric light cabinet. 
The entire body with the exception of the head is exposed to 
from 350 to 400 F. of heat in this body baking machine, for 
about a half hour. If the patient feels faint he is immediately 
removed from the cabinet. The patient is wrapped in several 
layers of Turkish toweling, great care being taken that every 
part of the skin is closely covered, else blistering and burns will 
occur. 

The after treatment, the objects for which such bakes are 
given, and the contraindications to the treatment are much the 
same as with the Turkish bath. 

Packs. — General perspiration may also be caused by the 
so-called hot or cold pack. For the hot pack the patient is 
wrapped in a sheet wrung out of hot water, and is then covered 
with blankets. He may also be surrounded with hot water 
bags. Or a sheet wrung out of cold water is wrapped around the 
patient, and he is then immediately surrounded with hot water 
bags and warm blankets. Perspiration is caused in each in- 
stance. The patient should be watched and not kept wrapped 
up too long, as sometimes there is considerable breathlessness 
and depression caused, especially when the arms are confined. 



HYDROTHERAPY 663 

These packs are used in rheumatic conditions, in toxemia, and 
sometimes in fever. 

Cold For Systemic Effect. — Cold water applied in some form 
is the most ancient means of reducing high temperature. Also 
it is the most satisfactory means, as it does not cause prostra- 
tion, and generally it is a stimulant to the circulation, and 
stimulation is often needed in serious fever conditions. 

The local application of cold reduces cutaneous sensibility, 
and if the cold is made intense at any spot, local anesthesia is 
caused. Cold applications cause the skin to become pale by 
contraction of the blood-vessels, and the condition termed 
"goose flesh" is caused by a contraction of the muscle fibers of 
the skin. The first shock of cold to the body may cause a 
sudden slowing or irregularity of the heart, but it rapidly 
recovers from the shock. 

As soon as the cold application ceases, there should be a 
rapid return of the blood to the surface of the body, a dilata- 
tion of the peripheral vessels, and the individual should feel 
warm. To hasten this reaction the patient should either be 
massaged or rubbed with a rough towel, and, if he is up and 
about, he should immediately put on his clothing. As the blood 
again rushes to the surface of the body the internal organs be- 
come depleted and the circulation becomes more normally 
equalized. 

In high fever the body temperature is more readily reduced by 
cold applications than when the patient is in a normal condition. 
Cold applications to reduce temperature vary in degree. In 
the order of the mildest to the most severe they are: tepid 
sponging, cold sponging, cold compresses, cold coils, cold sheets, 
cold sprinkling, and cold baths. Tepid sponging, leaving a 
film of water on the body, is often as valuable as the more 
severe cold sponging. Cold sponging should always be accom- 
panied by friction with a large rough washcloth. Friction of 
the muscles during cold applications has two objects, first, to 
prevent chilling, and second, to cause more blood to come to the 
surface of the body so that more heat will be abstracted. 
During the more severe cold applications a thermometer should 
be placed in the rectum and the reading frequently noted ; when 



664 TH E PRINCIPLES OF THERAPEUTICS 

the temperature has been lowered two degrees the cold applica- 
tion should cease, as it may fall somewhat lower before reaction 
occurs. 

The patient is generally covered with a blanket, or, if the 
weather is warm, with a sheet, and only the part being bathed is 
exposed to the atmosphere. To prevent chilling of the ex- 
tremities a hot water bag should generally be placed at the feet, 
and to prevent congestion of the cerebrum, an ice cap should be 
placed on the head. If cold applications make the patient 
more restless and do not cause the circulation to improve, they 
do more harm than good, and tepid water should be used, or a 
cold compress or a cold coil may be applied to the abdomen, if 
cold treatments are needed at all. 

It should be repeatedly emphasized that a cool room, electric 
fans if necessary, and the thinest bed coverings may prevent 
the necessity of using radical methods of reducing temperature 
in fever patients. 

A tendency to hemorrhage, or any congestion of the lungs, or 
any serious irritation or inflammation of the brain, or kidney 
insufficiency, pregnancy, and menstruation contraindicate the 
use of cold applications to the body. 

Most cold applications stimulate peristalsis, stimulate con- 
tractions of the bladder, may stimulate contractions of the 
uterus, and the severer forms of cold applications may cause 
temporary albuminuria. The urine should be watched for such 
a condition, and if albumin occurs after cold applications, milder 
treatments must be given. All metabolism is more or less 
stimulated by cold, and this is generally true even during fever. 

Whatever the cold application, it usually causes a chill or at 
least chilly sensations. If, during the application, a second 
chill occurs, the treatment should cease, and, if the patient 
continues to feel shivery for more than a few minutes, some circu- 
latory stimulant must be administered, brisk friction of the arms 
and legs given, and hot water bags should be placed around him. 

The frequency of cold applications to reduce temperature 
should rarely be more than once in six hours. Such treatments 
are often given every three hours, especially in typhoid fever. 
This allows the patient no rest, because it generally takes an 



HYDROTHESAPY 665 

hour to give a treatment, and rest is more essential for a fever 
patient than for an individual who is well, as with fever there 
is more muscle and nerve activity, which increases the 
temperature. 

Cold spongings, and the more severe applications of cold 
interfere with digestion; therefore, a cold treatment should not 
be given immediately after the ingestion of food. On the other 
hand, if food is given immediately after the treatment it may 
not be well digested, as the patient may immediately go to sleep 
from the physical tire and from the nervous relief. Therefore 
too frequent and too severe reductions of temperature by cold 
are inadvisable, even in continued fever. Proper, common- 
sense treatment and plenty of rest, especially in typhoid fever, 
will often keep the temperature down without resort to severe 
cold measures. In many cases of high temperature such as 
pneumonia, influenza, scarlet fever, and cerebral congestion, 
general cold treatments are inadvisable. 

Cold compresses to the abdomen, frequently changed, is a 
simpler method of reducing temperature than cold sponging. 
The coil, with ice water running through it by siphonage is a 
very valuable means of cooling the body, especially for local 
cooling. When it is placed over the abdomen, with the bones 
of the ilia and pubis covered with towels to prevent the local 
action of cold at these points, and with the coil not high enough 
to reach the heart, much heat may be abstracted, and it may 
remain on the abdomen to advantage for several hours, to be 
repeated when needed. 

The contraindications for such application of cold to the 
abdomen are menstruation, pregnancy, and a tendency to 
intestinal hemorrhage. It must be recognized that the blood- 
pressure may be raised in the abdominal vessels during cold 
applications, consequently to place ice bags over the iliac fossa 
when hemorrhage has occurred in typhoid fever is irrational. 
Cold to the abdomen more or less increases peristalsis and 
tends to prevent tympanites. 

It should be noted that severe cold should never be applied 
to the body when there is high blood-pressure, and especially if 
there is disease of the arteries. 



666 THE PRINCIPLES OF THERAPEUTICS 

The tub bath in typhoid fever, the so-called Brand treatment, 
is going, or has gone, into inocuous disuetude. When this 
treatment was first offered it was of great value in showing 
that cold was the safest means of reducing temperature in 
seriously sick patients, and typically in typhoid fever. But 
the method is too severe for ordinary home treatment and even 
for the hospital treatment of this disease. Too many atten- 
dants are required, there is too much general disturbance of the 
patient, often secondary chilling occurs, and the internal con- 
gestions are too great. 

A sheet wrapped around the patient and then sprinkling or 
douching him with cold water is another very unpleasant 
method of reducing temperature, and is generally inadvisable. 
Spongings with water at various degrees of temperature, even 
to the cold produced by ice in the water, are as severe measures 
as it is necessary to use to reduce temperature in fever. The 
temperature at or above which a typhoid patient should be 
sponged is 102 F., except perhaps during the first two or 
three days when a higher temperature may be allowed. 

In sunstroke rubbing with ice is better than ice baths and 
causes less shock. When the temperature begins to drop all 
cold treatments should be stopped, and the patient should be 
kept cool by fanning, by electric fans, and by cool drinks. 

Cold plunges, showers, or douches taken in the morning 
before breakfast as a general stimulant as soon as an individual 
rises have many advocates, and are very many times promoters 
of health and good feeling. On the other hand, in many 
instances the procedure is too severe, and in thin individuals is 
generally inadvisable, as it prevents the normal addition of 
weight. Many individuals with sluggish circulation do not 
react well to even the milder of these treatments and are chilly 
for an hour or more, consequently, for them such cold water 
measures are inadvisable. Cold applications in the morning, as 
at any other time, which cause cyanosis or albuminuria should 
be stopped. Whatever the cold treatment, brisk rubbing and 
brisk exercise for a few minutes in a warm room should always 
follow the cold application. 

In those who are weak and have a tendency to catch cold, 



HYDROTHERAPY 667 

cold spongings of the throat and chest, with brisk rubbing, each 
morning are of much benefit, and in tuberculous patients 
some such daily treatment, beginning with tepid water and 
gradually reducing the temperature to ordinary cold water, 
adds its quota in promoting the return to health. 

Alternate applications of heat and cold, which cause first 
vaso-dilatation and then vaso-contraction of the surface vessels 
is often of value in improving low tension and increasing a 
sluggish peripheral circulation. In cardiac distress when there 
is no edema, tepid baths at about 95 are very restful and 
relieve the laboring heart, but cold baths should rarely be 
given. 

Sponging with alcohol is cooling to the surface, and will 
lower temperature. Rubbing with alcohol is always stimulat- 
ing and bracing; but adding a dash of alcohol to a bowl of water 
used for sponging is simply absurd, unless only a psychic effect 
is desired. On the other hand, it is a mistake to use alcohol on 
the skin when the skin is dry and perspiration is desired. The 
obverse of this is also true, namely, in profuse perspiration 
and in relaxed conditions of the skin alcohol rubs are valuable. 

Hydrotherapy for Local Effect. — The local action of heat and 
cold is desired for effect on localized inflammation, acute or 
chronic, or for localized stimulation of parts whose nerve reac- 
tions and circulation are sluggish. Local action of heat and cold 
is also used for sedative effect, especially for pain. The local 
use of heat for inflammatory conditions coincides with resort 
to hyperemic measures for such a condition, and the physician 
must decide which measures he will use, namely, local heat or 
passive congestion by obstruction of the venous circulation. 
Localized heat for a more distant inflammation coincides with 
counterirritant methods, and which method for counterirritant 
action is better must be decided. 

Before using heat or cold on a localized inflammation the 
pathology of the condition must be noted. The well known 
local signs of acute inflammation will be evident, and the dilata- 
tion of the blood-vessels in the inflamed area and the attempt of 
the leucocytes to limit the region of inflammation requires no 
discussion. If the inflamed region is surrounded by tight, 



668 THE PRINCIPLES OF THERAPEUTICS 

hard tissues, the swelling that must occur will cause pain, more 
or less intense, depending upon the amount of swelling and the 
resistance of the tissues. If the part inflamed is easily ex- 
panded or dilated the pain will not be so severe. Cold to the 
inflamed part will inhibit the activity of the circulation, pre- 
vent the leucocytes from increasing in numbers in the inflamed 
area, will more constrict tissues and prevent expansion, and if 
the injury to the part which caused the inflammation is not 
infected, the inflammation may be aborted by the cold. If, on 
the other hand, the cause of the inflammation is an infection, 
cold will inhibit nature's method of combating the infection 
or inflammation. However, heat in such a condition, i.e., when 
the inflammation is caused by an infection, may increase the 
activity of the germs of infection as well as promote necessary 
congestion of the area, nature's method of surrounding infective 
germs. The heat may dilate surrounding vessels so that na- 
ture's process of closely circumscribing the infected area may 
be defeated by allowing extravasations and migrations of the 
germs of infection to larger areas. Heat, on the other hand, by 
relaxing tissues may diminish the pain and frequently promotes 
absorption of exudate, and thus diminishes swelling. Cold may 
diminish pain by its anesthetic effect and may prevent exudate 
and swelling by causing contraction of vessels. It is thus seen 
that the decision as to whether heat or cold shall be used for a 
localized inflammation must be arrived at after careful consid- 
eration. 

If pus is present in a part, heat will make its development 
more rapid, and will cause it generally to point toward the region 
of the heat application. Or, at the border-line as to whether 
pus will be formed or not, hot applications may cause pus to be 
formed. Too much heat, or prolonged heat on the skin may 
so destroy its nutrition, that the incision made to evacuate pus 
may not readily heal. For these various reasons poultices and 
hot moist applications are not as much used as formerly. 

The local effect of dry heat is described on page 632. 

Moist heat is best applied by napkins, or gauze, wet with one 
part of alcohol to three or four parts of hot water, or with some 
simple, lotion as witch hazel and hot water, and the wet pad, 



HYDROTHERAPY 669 

thoroughly covered with oil silk or rubber tissue, is then 
bound to the part with a roller bandage. Such an application 
need not be changed more frequently than once in three hours. 
Hot applications or cold applications with corrosive sublimate 
solutions are generally inadvisable on account of the serious 
irritation and inflammation of the skin that may be caused. 
Corrosive sublimate may be applied for a short time to an in- 
fected open wound. Various other wet dressings may be used, 
but the above are as valuable as any. 

When moist heat is to be applied to a larger part of the body, 
as the kidney region, large towels or flannel wrung out of hot 
water and covered with other towels, or a rubber sheet, and 
bound tightly to the back is a good method of making such 
applications. If counterirritation is desired, alcohol or oil of 
turpentine may be sprinkled on the wet towel. A hot water bag, 
or an electric pad, will always allow the wet application to remain 
hot longer, and therefore cause less trouble and less disturbance 
of the patient. 

Heat to the abdomen may be applied in the same manner. 
Both dry heat and moist heat over the stomach tend to relax 
pyloric spasm and hence stop stomach pain and promote evac- 
uation of the contents of the stomach into the duodenum. 
Intestinal colic is also relieved by moist heat. When a hot tub 
bath cannot be taken in renal or hepatic colic, hot fomentations 
to the whole abdomen will aid in relaxing the spasm, of course 
in conjunction with the necessary morphine injections. A hot 
sitz bath is beneficial in spasmodic dysmenorrhea, in lumbago, 
and in chordee. Hot moist applications to the throat will aid 
in overcoming spasmodic croup, and around the neck in relaxing 
the spasm of stiff neck (torticollis) . Putting a sprained ankle 
into a warm foot bath and gradually adding hot water will 
soon stop the pain. Later the ankle may be strapped, unless 
the hot water treatment is to be repeated. 

Hot fomentations by means of small pads applied for short 
periods, then intermitted for two or three hours, are of value 
in relieving eye pain and conjunctivitis. 

Small baking machines for different parts of the body are of 
value in treating chronic arthritis, the results of injuries, neuritis, 



670 THE PRINCIPLES OF THERAPEUTICS 

etc., but diathermy is supplanting this method of treat- 
ment. Too much local baking is not good for joints or other 
tissues. 

The Local Action of Cold. — Ice bags, or cloths wrung out of 
cold water, may be used for various conditions; or ice poultices 
may be made with cracked ice and sawdust or bran. Cold in 
any form applied to an inflamed joint or gland may inhibit 
the inflammation, but it often fails. An injury, however, a 
sprain or bruise, is well treated by a cold pack, and no method 
is better than the following: a napkin, saturated to dripping 
with one part alcohol and three or four parts of water, is 
wrapped around the region and covered with rubber cloth, 
and the whole is then fastened with a bandage, not so tight that 
slight evaporation may not occur around the edges of the 
bandage. This continuous evaporation will cause the part 
to become very cold. 

Variously shaped ice bags may be obtained for applying cold 
to different parts of the body. An ice bag over an inflamed 
appendix has long been thought to inhibit the inflammation, and 
often apparently succeeds. This must be a reflex action; direct 
action on the appendix through the abdomen is impossible. 
Absolute bed rest, proper evacuation of the large intestine, and 
starvation are probably more valuable than the local application 
of ice, and, in fact, application of heat locally is many times 
as valuable. The same may be said of the application of ice 
to the chest in hemorrhage from the lungs; the hemorrhage 
stops, but it is a sequence of events rather than because of the 
local application of cold. The ability of ice in the vagina and 
uterus to stop uterine hemorrhage by causing contraction of the 
uterus is recognized. Ice or cold applications on the lower 
abdomen will cause contraction of the bladder and also of the 
uterus. Ice to the perineum is sometimes valuable in prostatic 
irritability, and to stop seminal emissions. Ice or cold appli- 
cations to the anus and rectum, both for external and internal 
hemorrhoids, is of value, and when frequently applied cause a 
better tone of the region. The ice bag in pericarditis, pleurisy, 
and meningitis (both cerebral and spinal) has been proved to be 
of value. Ice to the mastoid region may inhibit or limit 



HYDROTHERAPY 67 I 

inflammation there, but it has not been proved that ice or cold 
applications are valuable in inhibiting pneumonia. The ice coil 
is often of more value and is better adapted for applying cold 
to a part than the ice bag or cap. Cold should not be applied 
to any one part too long, as it not only inhibits the nutrition 
of the part, but may even cause death of the tissues. 

When a part is to be frozen for anesthesia, ethyl chloride 
spray is more efhcient and better to use than ice. While the 
ethyl chloride spray is being used, gas, lamps, and matches must 
not be lighted. 

Special Forms of Water Treatment. — The various forms of 
special methods of using hot and cold water have special names, 
and these special treatments are many. There are the various 
kinds of baths, hot and cold packs, and wet sheets, some of 
which have been mentioned. There is the hammock bath, 
which is not dissimilar to the tub bath. The hot sitz bath 
is of great value in relieving congestion in the head and in 
bringing more blood to the surface of the body and thus 
relieving localized congestion in the abdomen and pelvis. The 
foot bath also is an efficient means of relieving cerebral con- 
gestion, and of dilating the pelvic vessels. Mustard or salt 
added to these baths, causing irritation of the skin, may be of 
more value at times than plain water. Both of these ingredients 
may cause inflammation of the skin, and if there is eczema 
or dermatitis they should not be used. Insomnia may be 
relieved by a hot foot bath taken before going to bed; cold 
feet are not conducive to sleep, and individuals with poor 
circulation should wear bed socks. A hot water bag at the 
feet is not advisable, at least if it is to be frequently repeated, 
as it tends to soften the tissues, cause perspiration of the feet, 
and increase the tendency to catch cold. Any dry warmth to 
the abdomen may aid in producing sleep. 

Sea salt is often added to a general bath as it causes greater 
irritation of the skin and therefore a longer increased peripheral 
circulation than occurs from the plain bath. Sea bathing is 
more stimulant than fresh water bathing, and if exhaustion is 
not caused by bathing too long in the surf the general stimula- 
tion after coming from the ocean bath lasts for some time. 



672 THE PRINCIPLES OF THERAPEUTICS 

Individuals who are weak and whose circulation is poor should 
not attempt the hardship of surf bathing. 

Sulphur baths are advocated for various conditions such as 
rheumatism, and for some skin diseases, and they are especially 
advised to eliminate metallic salts from the body, typically 
mercury after it has been long administered for syphilis. These 
baths are best given at the sulphur springs. It has not been 
shown exactly what benefit occurs from a sulphur bath besides 
the psychic effect. Mud baths given at these springs are also 
considered of great value. Mud applications to a rheumatic, 
gouty, or otherwise diseased joint may be of benefit as a 
poultice proposition, and the effect is doubtless no different 
from that caused by a similar local application made at the 
patient's home, unless the mud is radio-active. 

Oil of pine added to a bath makes the so-called pine needle 
bath. The effect is stimulating and irritating to the skin. 
The inhalation of the vapor of pine while the patient is in the 
bath may be of some advantage in throat and upper air passage 
inflammation, but this action can be more easily obtained by 
direct inhalation of mixtures containing pine oils. 

The carbon dioxide bath has been much used in cardio- 
vascular-renal disease and to reduce high blood-pressure. 
These baths were lauded at the Nauheim springs in Europe, 
and have acquired celebrity for that reason. The object is to 
furnish bubbles of carbon dioxide by mixtures of salts that will 
produce effervescence. These bubbles strike the skin and 
cause slight irritation and hence increase peripheral circulation, 
to the relief of internal congestions and a slight lowering of 
blood-pressure. A patient with low blood-pressure should 
not take this kind of a bath. These baths, whether given at 
the springs, in sanatoria, or at home, should ordinarily not be 
used in chronic nephritis. Salts for these baths can be obtained 
in packages ready for use. 

The Nauheim baths are divided into three types: the natural 
carbonated salt bath; the bath in which either the carbonated 
water or the brine is artificial; and the bath in which both the 
brine and the carbonic acid are artificial. The natural bath is 
found at Nauheim. Natural brine baths have been thought by 



MASSAGE 673 

some to have better action than artificial brine baths; con- 
sequently it is thought that the artificially carbonated bath 
with natural brine is a little better than when the water is 
carbonated and the brine is added, or when both the brine and 
the carbonic acid are artificial. 

Various forms of douches, both hot and cold water, are used, 
best directed from a douche table, which can govern not only the 
direction of the douche, but also the temperature of the water 
and the force with which it is projected. These douches are 
termed the sheet, the circular, the revolving jet douche, and 
the needle spray. The effect of some of these douches may 
be profound, and care should be taken lest shock is caused. 
Steam douches are sometimes given. A hot douche followed 
by a cold douche is termed the Scotch douche. The head 
should not be treated by douches, although a simple shower may 
be directed over the head. 

MASSAGE 

This is one of the most useful of the so-called physical thera- 
pies. It can be given gently enough to quite pain, or strenuous- 
ly enough to break up adhesions. It can be given to promote 
the nutrition of the skin and the flow of blood in the surface 
veins, or to increase the flow of blood and lymph in the 
muscles, and thus promote muscle nutrition. It can be given 
to quiet a patient to sleep, or to stimulate him to increased 
exertion. It can be used in the seriously sick to gently promote 
the sluggish circulation in the muscles and skin and thus to aid 
in the elimination of toxins, or it can be used to remove the 
fatigue of the athlete to prepare him for renewed effort. 

The operative technique of massage cannot be taught by 
book, it must be learned by personal operation under the in- 
struction of an expert and by long practice on the human body, 
and even then a good masseur, or masseuse, is, like the poet, 
born and not made. A physician rarely has the time or the 
training to do good massage, but he should sufficiently under- 
stand the subject to decide that massage is advisable; the kind 
of massage needed; the length of time it should be given; and the 

improvement to be expected. He must also recognize when 

43 



674 THE PRINCIPLES OF THERAPEUTICS 

massage is contraindicated and when it is doing harm. 
After selecting the operator for a patient, generally best one of the 
same sex, the physician should order what he wishes done, as he 
would give any other order for the management and care of his 
patient. 

The nervous effect of the massage on the individual has 
largely to do with the personality of the operator. The inti- 
mate relations into which these two people must come, the 
operator and the patient, necessitates that the operator be force- 
ful, cheerful and have a pleasing personality. There is no 
question that too vigorous, or ill advised, massage on sensitive 
parts of the body may render a patient very nervous and irri- 
table. On the other hand, there is no question that general 
massage is sometimes very quieting and soothing, and a calm, 
gentle operator may almost cause a hypnotic quieting influence. 
There is without doubt some electrical exchange between the 
operator and the patient. Hence in nervous individuals, or 
where massage is used to quiet and to produce restfulness and 
sleep, the operator must not only be an expert, but well chosen. 
For massage that is not general, but for some local disturbance, 
such a careful choice is not needed. 

Generally no lubricant should be used; at least a competent 
operator does not need a lubricant. He knows what parts of 
the body to operate gently; he is careful not to rub on tender 
spots too severely; and is careful not to irritate and bruise the 
skin. In massaging very hairy persons a little talcum powder, 
or some oily powder, may be used, or a wool fat made less 
tenacious and more emollient by oil of sweet almonds may 
be used. Cocoa butter is a lubricant frequently used. Vase- 
line or any other petroleum oil should not be used, as it is likely 
to irritate sensitive skins and promotes the growth of hair more 
than other fats. 

If there is an eruption on the patient's skin, some thin, 
clinging garment should cover him and the massage be done 
through it. It is, also not necessary for the skin to be absolute- 
ly uncovered if the object is to massage some deep-seated mus- 
cle or nerve. 

General massage should ordinarily last about an hour, each 



MASSAGE 675 

extremity being operated upon about ten minutes, the rest of the 
time being spent on the body. With very large or very fat 
people the massage may be given for a longer time than an hour. 
At first, general massage should be given daily; later less fre- 
quently. If pain is caused the massage should be stopped; or 
if the patient feels exhausted after the massage, subsequent 
treatments should be shorter. The best time for massage is 
some hours after a meal, and if it is found to be quieting to the 
patient, it may be given just before bedtime. The patient 
must always be at rest, and the operator must be at ease. 
Needless to state, it is well for the patient to have previously 
had a bath; and the operator should have clean hands, short 
nails, and wear no rings. With these simple precautions, in- 
fection will not be rubbed into a tender skin. 

It is best for the patient to lie on a stiff bed or couch, between 
blankets, and otherwise without covering, unless a thin cover- 
ing is advisable. For general massage usually manipulations 
are begun on the lower extremities, then the arms, then the 
back, then the chest, and last the abdomen. 

There are technical names applied to the various kinds of 
massage. Those that are most important are : effleurage, which 
is stroking \ friction, which is rubbing; tapotement, which is beat- 
ing or tapping; petrissage, which is kneading. Rapid tapping is 
termed vibration; pullings, stretchings, and bendings are part 
of practical massage. 

The most gentle of these applications is effleurage, which con- 
sists of gentle rubbing and stroking, generally from the periphery 
toward the center, to promote the surface venous circulation. 
If this stroking is rather forceful, it also aids the flow of the 
lymph in the lymph vessels. This rubbing and stroking should 
generally be slow, and in tender parts, very gentle. Friction is 
simply more active rubbing, and the strokes may be upward, 
or in circles about a sore spot or joint and where there is ex- 
travasation or exudate, which it is the aim to remove. This 
kind of rubbing may be used on painful nerve regions to 
change the circulation in the deeper parts, provided there is no 
inflammation. 

Tapotement is when the muscles are tapped with the fingers 



676 THE PRINCIPLES OF THERAPEUTICS 

or with the hand or gently slapped with the flat of the hand. 
Gentle, rapid percussions represent the vibratory treatment. 

By petrissage is meant the grasping of a muscle or group of 
muscles and kneading, squeezing, and lifting them; or the 
muscles may be rolled with the fingers or hands. The effect 
of this type of massage is to improve the circulation of the blood 
and lymph in a muscle. Muscle cramps and myalgia are thus 
treated, and fatigue products are thus removed from the 
muscles. 

The first effects of proper massage should be an increased 
activity of each manipulated muscle as shown by its becoming 
larger and firmer, due to the increase of its blood supply. 
The after effect of a general massage should be, for some time 
at least, an increased tone. If general massage is doing good, 
this tonicity should last longer and longer after each treatment. 
The color of the skin should improve on account of its increased 
circulation, and it should become more moist; a rigid, hard, 
rough skin should become softer and more elastic. If this 
general massage is of benefit, the feeling of fatigue should be 
diminished, the patient should be less nervous, and general 
aches and pains should, at least temporarily, be abolished. 
Not only hysterical, but neurasthenic and convalescent patients 
are likely to have sore spots or tender spots on various parts 
of the body. Whether these are due to a disturbed circulation 
or to an imperfect absorption and elimination of metabolic 
salts, or to some other unexplained cause, they should all be 
improved by properly conducted massage. If the general 
circulation improves, the patient should sleep better, and 
his appetite and his digestion should be better. 

Ordinarily general massage should represent all the different 
forms, beginning with gentle stroking, to be followed later with 
the more or less vigorous movements. The temperature of the 
body may rise slightly, especially if it has been subnormal. A 
paralyzed extremity in which the temperature has been sub- 
normal may have its temperature raised several degrees, due 
to the improvement in circulation. As more blood flows to 
the surface of the body, unless the patient is very nervous or 
is irritated by the massage, the pulse becomes slower. Occa- 



MASSAGE 677 

sionally with this slight rise in blood-pressure there is a flushing 
of the face, and some "full-head" feelings. A blood count will 
often show an increase in the number of corpuscles, due to 
stimulation of the circulation in the blood and lymphatic 
vessels of the muscles. With improvement in the circulation 
and with an increased blood-pressure more urine is generally 
excreted. 

It should be emphasized that if pain is caused by massage, it 
should be stopped, at least on that part of the body; if the 
patient seems exhausted, it should be given for a much shorter 
time at the next seance. If no improvement takes place and 
a patient is made more nervous, or dreads the massage, it is 
generally an indication that the massage should cease, or that 
a more satisfactory operator should be obtained. 

General Indications. — The general indications for massage 
are neurasthenic and hysterical conditions; general muscle 
weakness; slow convalescence after serious illness; as a part 
of the "rest cure;" for more or less bed-ridden or house-ridden 
patients; to promote more active metabolism and nutrition; 
and to increase secretions and excretions. Also massage is of 
value in local disturbances in joints and tendons; to remove exu- 
dates; to break up adhesions; and in the later stages of neuritis. 
Where there is a sprain, or where there is some inflammatory 
exudate which is slow to resorb, short and frequent treatments 
are required. In aiding resorption of such exudates, rubbing 
and strong stroking, often concentrically, are the most effective 
measures. The vibratory method is of value in neuralgias, 
not for neuritis. Nerves, muscles and tendons may at times 
be stretched, and more or less joint extension may be required, 
but in operating other than very gently on a joint the diagnosis 
must be positively decided upon, and roentgenograms should 
be obtained to determine the condition of the joint, bones, 
and tendons. 

Massage to stimulate and promote metabolism and nutrition 
should generally be given daily, at least for a time, especially 
to patients who are in bed or convalescent, and to those who are 
undergoing a rest treatment. To ambulatory patients and 
to patients who are confined to the house and cannot take 



678 THE PRINCIPLES OF THERAPEUTICS 

sufficient exercise, but are not bed-ridden, and to patients 
with chronic debility, as arthritis deformans, two or three 
times a week is frequent enough for the treatments. 

It should be recognized that massage is only a part, though a 
valuable part, of the treatment of many conditions, such as 
locomotor ataxia or other spinal disease; multiple neuritis; the 
after effects of chorea or infantile paralysis; broken compensa- 
tion in heart disease; and such a simple condition as constipation. 
In patients who are obese and cannot properly exercise, massage 
and muscle movements are of great benefit. In all cases of 
paralysis it should be remembered that a voluntary move- 
ment of a muscle is of more value than a passive or mechanical 
movement. 

The value of massage, manipulations, muscle exercises, and 
stretchings after fractures, dislocations and sprains, is too self- 
evident to require discussion. Gentle massage should begin with 
some sprains as early as the second day after the injury, and 
straps around a sprained joint which allows use of that joint is 
really a species of massage, as every movement causes some fric- 
tion and rubbing under the straps. Baking and diathermy are 
often of great value in promoting absorption of blood and exu- 
dates and hastening recovery. If there is a hematoma, rest and 
bandaging are at first essential; later heat in some form, and 
still later massage, not too forceful. In inflammation of a ten- 
don heat and later massage and bandaging is the treatment. 
Stiff necks, cramps of the muscles in any part of the body, and 
headaches are often relieved by massage. For headache, mas- 
sage of the back of the neck and down the spine as well as of 
the head is often of benefit. 

The value of manipulations of the breasts to promote the flow 
of milk when there is some localized congestion is recognized by 
all obstetricians and obstetrical nurses. Uterine massage in 
certain conditions has its advocates, provided there is no acute 
inflammation in the pelvis. Prostatic massage through the 
rectum is often of benefit. 

Massage of the face for cosmetic purposes, unless there is 
some cicatrix from an injury, is probably too frequently done. 
With a dry skin it is of considerable advantage, but when the 



MASSAGE 679 

skin is oily, it tends to promote such secretions, and especially 
if massage is done with the use of fats. There is too much facial 
vibration and facial massage done to-day; the value is largely 
financial only. Massage of the scalp is often of value when 
there is falling of the hair, and when the nutrition of the hair 
follicles is impaired. 

It should be insisted upon that massage is only one form of 
physical treatment. A condition may req\iire as well one or 
more of the following: hydro therapeutic measures, electrical 
measures, or the local application of heat. 

Contraindications. — For a long time it was thought that 
massage should not be done when there was an increased tem- 
perature or fever. Strong massage should certainly not be 
given under such conditions, but in acute illness gentle rubbing, 
toward the center of the body, improves the sluggish peripheral 
circulation and also the lymphatic circulation, and hence is 
of value. Of course any kind of massage that much increases 
the temperature would not be of benefit. In all cold water 
applications in fever more or less massage is done, as it is advis- 
able to bring the blood to the surface of the body during such 
applications in order to increase the abstraction of heat. 

It may be here noted that when the skin of the patient is hot 
and dry, alcohol rubs are not indicated. If there is profuse 
sweating, warm alcohol rubs are of benefit. A dash of alcohol 
in a quart or more of water does not represent the use of alco- 
hol; the effect is purely psychic, both on the patient and the 
nurse. 

Acute inflammations of the skin preclude all massage. Ve- 
nous thrombosis and phlebitis prohibit massage in these regions. 
Acute pus formations should not be massaged. Menstruation 
is not necessarily a contraindication; if the flow is too profuse 
and the extremities are cold, it may relieve the pelvic congestion. 
There is no reason why massage should not be done during preg- 
nancy, provided it is not done on the abdomen. Tendencies 
to hemorrhage in any part of the body, other than the uterus, 
generally contraindicate massage, such as ulcer of the stomach 
or duodenum, and when there has been hemoptysis. A bone 
that is acutely inflamed must surely not be massaged; and the 



680 THE PRINCIPLES OF THERAPEUTICS 

region of an infection should not be massaged. Dilated vessels 
of all kinds should not be irritated by rubbing or massage. In 
arteriosclerosis and atheroma, and many times in high blood- 
pressure, massage should not be done. In serious kidney lesions 
and in diabetes general massage should be used with great care, 
as, like over-exercise, too large an amount of toxins may be 
thrown into the circulation at one time, more than can be 
quickly excreted, and uremia in the one case and diabetic coma 
in the other may be caused. 

The fallacy of osteopathy being a subject of medical import- 
ance is recognized by the profession but not by the laity. That 
an osteopath may become an expert masseur and give fine 
massage is, of course, a fact, although he repudiates the term 
massage and calls it "manipulations. " The osteopaths attri- 
bute almost all disturbances to a displaced vertebra, and seem to 
repudiate physiology, pathology, bacteriology, and most every 
other branch of medical science, consequently they place them- 
selves outside of the realm of recognition by the medical 
profession. 

The chiropractor goes the osteopath one step better — or 
worse. The writer has heard them claim that they were better 
than osteopaths because they a can do in five minutes what it 
takes an osteopath an hour to do." The chiropractor also 
always finds a displaced vertebra which he hammers, or pounds, 
back into place. His operations are neither massage nor 
manipulations, but "adjustments," and to keep an offending 
vertebra in place may require from two to three treatments a 
week for even as many as a hundred "adjustments." 

PHYSICAL EXERCISE 

Exercise is necessary for health, and its value is much better 
understood and recognized than it was a few years ago. Conse- 
quently, the physician very frequently finds that it is not only 
necessary and advisable for him to order various forms of 
exercise for his patients, but also many times to curb excessive 
exercise. 

General Considerations. — Exercises are termed "active" 
when the patient performs them himself; "passive" when some 



PHYSICAL EXERCISE 68 1 

one else causes the different parts of the body to move. Exer- 
cise with resistance is when the individual pulls against the 
resistance of the operator, or the operator pulls against the 
resistance of the patient. 

During exercise the muscles of the body receive more blood 
and metabolism is improved; with hard exercise weight is lost, 
and therefore increased exercise is utilized to reduce obesity. 
Muscle activity reduces the glycogen of the muscle, increases 
the carbon dioxide output, and increases the waste products, 
such as acid potassium phosphate, creatin, and lactic acid. Also 
during exercise the nervous tissues undergo chemical changes. 
The greater the amount of exercise, the greater the supply of 
blood to the muscles, the greater the oxygen and carbon dioxide 
exchange in the lungs, and the greater the amount of general 
oxidation that occurs in the body. There is also an increased 
amount of water excreted by the skin and lungs, and, if the 
patient does not perspire freely, by the kidneys. If water is 
not supplied, the liquids of the body will be increased in density. 
If the individual stops exercise suddenly, these waste products, 
and the so-called fatigue substances, may remain in the muscles 
and cause a feeling of general tire and soreness or even pain in 
the muscles exercised. Gentle massage, a hot bath, or a cold 
shower and rubbing will remove these fatigue products, and if 
the individual reacts quickly and has not over-worked, he will 
immediately feel refreshed and ready for ordinary activities. 
If he has been over-worked, he will be relaxed and weary, and 
he should not eat at that time, as he will not well digest his 
food. If he has exercised to exhaustion he may be nauseated 
and actually vomit and have palpitation of the heart. Severe 
exercise may cause albumin, casts and blood cells to appear in 
the urine. 

With normal exercise the systolic blood-pressure only slightly 
increases, and after the exercise has ceased, the blood-pressure 
should return quickly to what is normal for the individual. If 
an individual's circulatory strength is not good, exercise does 
not as rapidly increase the blood-pressure, but when the blood- 
pressure has become increased, it will remain for some time 
above normal after the exercise has ceased. Such a behavior 



682 THE PRINCIPLES OP THERAPEUTICS 

of the blood-pressure shows that the individual is over-exercis- 
ing and over- working. 

As with massage, exercise of any muscle will increase its 
nutrition and also its strength, and general exercise improves 
the general circulation and the body metabolism. If the 
excretory organs are insufficient, after more or less severe 
exercise, metabolic products, some of them toxic if they accumu- 
late in the blood and tissues, will cause weariness and, perhaps, 
drowsiness; or, on the other hand, the nervous system may be 
irritated and the individual be sleepless. Serious poisoning 
may occur from over-exercise in such conditions as diabetes 
and nephritis. 

The excretion from the skin is largely water, a very few salts, 
and traces of urea, unless the kidneys are pathologic, in which 
case the excretion of these substances by the skin may be 
slightly increased. The excretion from the lungs under ordi- 
nary circumstances is only carbon dioxide and water. The 
excretion from the kidneys is, besides water, urea, uric acid, 
creatin (as creatinin), ammonia, and various salts. 

During rest, and especially during sleep, the tired muscle 
stores glycogen for its future activity and the neuron stores 
chromophile substances, and both muscle and nervous tissues 
are ready for renewed activity. 

The necessity for proper exercise for a child to grow normally 
and for a youth to normally develop need not be urged, but it 
is necessary to take note of the fact that the over-use of any one 
muscle or of any one set of muscles tends to shorten that mus- 
cle or group of muscles, and more or less deformity may occur. 
This is very evident in occupations that use only one side of the 
body, and it will also occur in children who do not properly use 
all of their muscles. Also, over-exercise of some muscles tends 
to cause bone deformities. Repeatedly standing in a bad posi- 
tion or sitting in a bad position will surely cause deformities, and 
some such mistakes, or the carryng of weights always in one 
arm, or over one hip, are almost always the cause of scoliosis. 
Children who have eye defects and learn to tip their heads to one 
side in order to have better single vision, have the habit of 
cocking the head permanently established. 



PHYSICAL EXERCISE 683 

The Swedish system of physical culture, termed the Ling 
system, is the groundwork of drills by classes. The object of 
this kind of gymnastics is to equally develop all parts of the body 
and is therefore of great value for growing boys and girls, and 
even for youth. 

Owing to mistakes in the character of the exercise of early 
childhood, and owing to deformities caused by previous disease 
or injury, it is very necessary that children on entering school 
should be examined as to their muscle and bone developments. 
The examinations should be made by regularly appointed medi- 
cal experts, to determine what sort of special treatments in the 
way of exercises are necessary for the individual child to over- 
come a deformity already present, or prevent the development 
of one that is impending. It is also self-evident that a physical 
exercise that will be of benefit to a strong, sturdy boy may cause 
injury, especially to the heart, of a boy who is weak. A child 
that has a cardiac defect must certainly not be allowed to take 
strenuous exercise, or to take part in competitive games. 

The harm that can be caused young growing boys by tobacco 
should be more seriously considered by preparatory schools and 
by the principals and teachers of all schools. It is a crime that 
so many of our young boys are allowed to smoke cigarettes 
during the growing period. The development of the heart and 
lungs is seriously interfered with by tobacco, and it is generally 
recognized by athletic directors everywhere that, if a young man 
is to train for competitive athletics, he must stop his tobacco. 

The various forms of muscle movements, either in classes or 
as individuals, may be learned from books devoted to the sub- 
ject of calisthenics. The more strenuous out-of-door exercises 
may be learned from books on training and from physical in- 
struction in schools. 

The various apparatus for exercise of different parts of the 
body can be best studied at a well equipped gymnasium. Partic- 
ular exercises to overcome particular defects should be advised 
only by one who has become expert in such work, and by skilled 
orthopedists. 

Zander Methods. — Gustav Zander invented a series of ingen- 
iously efficient instruments for causing muscle and joint move- 



684 THE PRINCIPLES OF THERAPEUTICS 

ments of all parts of the body, and this system of exercise has 
been developed in many cities of this country under the name of 
" Zander Institutes." These instruments, which are generally 
run by electric motors, can cause vibrations, extensions, and 
exercise of most any set of muscles of the body; but it should not 
be forgotten that one voluntary movement is of more value in 
aiding recuperation of a muscle or nerve than many passive 
movements. 

Combined instruments have been invented which may cause 
exercise of many parts of the body, hence elaborate equipments 
of hospitals and sanatoriums with Zander machinery is not 
necessary. 

The diagnosis must always be carefully made as to whether 
such powerful machine movements are advisable, especially 
when the joints are to be exercised. Also an orthopedic expert 
should watch and study the results of such treatment, lest harm 
be done. In some instances it is advisable for a semi-paralyzed 
patient to have a machine installed at his home that will give 
him the kind of exercise required, provided it is decided that 
such a physical treatment is better than that which could be 
given by a masseur. 

Exercises for Children. — It is recognized by all educators that 
growing children must have regular exercise. Therefore some 
schools have installed gymnasiums, and all schools teach a cer- 
tain amount of calisthenics, combined with marching and more 
strenuous regulated movements and more or less strenuous 
games. All of these exercises are of great advantage to prop- 
erly develop young girls and boys. If these children are not so 
watched and supervised, they are likely to over-develop certain 
groups of muscles by doing only the things that they like to do. 
They, also, readily develop incorrect standing, have improper 
methods of carrying their books or other loads, sit in awk- 
ward positions at their desks, or lean over them to study or 
write. 

Toward prevention of such defects the school desks and chairs 
should be properly adjusted to the height of the child. Eye 
defects should be corrected, as such tend to bad postures of 
children. Ill-fitting shoes, and improperly heeled shoes, and 



PHYSICAL EXERCISE 685 

shoes with the heels worn sidewise can all be the start of ortho- 
pedic defects. 

Walking is the most utilized exercise, and one of the best. 
The speed of walking and its duration and the character of the 
ground are important factors in the amount of actual exercise that 
one receives from walking. Rapid walking and running exercises 
the whole body, and even the abdominal organs are stimulated. 

Running is strenuous exercise, and rapid running is very 
exhausting, and should be prohibited when there is cardiac or 
circulatory weakness. A slow trot for a short distance, then 
walking, and then trotting, is good exercise. 

Riding on a bicycle often puts the body in an abnormal posi- 
tion, exercises certain muscles only and does not exercise all the 
body; also, if the bicycle is much used, sitting on the saddle and 
straining, with the strong leg movements needed, may deform 
growing pelvic bones, especially in girls, and leaning over the 
handle-bars does not allow good chest movements. 

Baseball is good exercise and a good game for any boy at any 
age, provided he has no defects that would preclude the running 
part of the game. Basketball is strenuous, and those who have 
defective hearts or are not sturdy should not be allowed to play 
this game. Vaulting, jumping, swinging of clubs, using dumb- 
bells and parallel bar gymnastic work are all good exercises, 
when not overdone and when properly supervised, especially 
for growing children. 

Exercises for Youth. — Wrestling is always a question of 
weight, and a light-weight individual should not wrestle with a 
heavy-weight, as he may seriously strain his heart and may per- 
haps become more or less permanently injured. Sparring can 
hardly help but develop a certain amount of temper; however 
pleasantly a boy or man may use his fists, he is likely to develop 
pretty strenuous pugnacious feelings. Both sparring and 
fencing, especially the latter, cause a great deal of nervous ten- 
sion, and this should be taken into consideration in advising 
such exercises for young men. 

Bowling is especially good exercise, provided that the bowl- 
ing alley receives plenty of fresh air and is not in some poorly 
ventilated cellar. Tennis is a fine game for any age, provided 



686 THE PRINCIPLES OP THERAPEUTICS 

that the person taking part in it does not have a defective heart. 
This jumping and springing exercise is not good for such 
defective individuals; otherwise the exercise is splendid. Row- 
ing is good exercise if it is done deliberately and not against 
time or against a competitor. When the rowing is competitive, 
especially if the individual has not been sufficiently trained, or 
if the distance is too great, heart strain is easily caused, and 
even permanent cardiac disability. Horseback riding is again 
becoming the vogue. It is splendid exercise for the whole body, 
especially if the horse trots; if the horse is spirited the exercise 
becomes strenuous. 

The development, in many of our cities, of the class method 
of instruction in the various arm, leg, and body exercises; the 
gymnasiums and swimming pools in the Young Men's Christian 
Association buildings; and the tramping, marching, and other 
exercises for the Boy and Girl Scouts are all of great benefit to 
young people. 

The Delsarte system of physical culture is taught more or less 
privately, sometimes in classes, often by women teachers, and is 
a special form of exercise aimed to teach good carriage and, 
especially, how to properly walk and properly stand. This 
teaching has been more or less superseded by the dancing craze, 
and now, not quite so much as two or three years ago, old people 
as well as young are taught to dance. Dancing is splendid 
exercise, and teaches graceful movement and graceful carriage. 
However, young people carry this craze more or less to excess, 
and some of these dances are absolutely inexcusable from every 
decent and moral standpoint. Public dancing between the 
courses of a meal, or in the midst of the different courses, is 
against good sense; also it is unphysiologic to dance immediately 
after a meal. Too much dancing is not good for anyone, and 
excessive dancing by young girls and by older people and by 
anyone with a cardiac defect is absolutely unjustifiable. 

Exercise For Adults.— Besides walking, horseback riding, and 
tennis, golf represents one of the best exercises for adults. The 
walking on the golf course may be done slowly or rapidly as one 
desires, and at golf the mind is taken off from business, and 
the nervous tension is not great. The only tendency of the 



PHYSICAL EXERCISE 687 

golfer is to strive to play too long in one day or at one time, 
and he seems to be as proud of telling how many holes he has 
played as is the novice in automobile driving to tell how many 
miles he has covered in a certain time. When the number of 
holes played is the object of the game, the exercise can do 
harm, especially to the middle aged; but if the individual, 
business or professional man, lives a strenuous, nervous life, 
there is nothing better than golf as a sport, as an exercise, as a 
relief from mental strain, and to generalize the circulation of 
the blood. If, however, the individual is physically weak and 
has circulatory defects, even golf, as well as walking, may be 
a disadvantage to him and actually cause harm. Such an 
individual should first seek advice as to the proper diet and 
proper amount of exercise he should take, and frequently a 
rest cure is what he really needs rather than exercise. 

Fishing can be made strenuous or as restful as the laziest man 
could desire ; but it presents perhaps the greatest amount of mental 
rest of any sport that can be offered. Hunting is always more 
or less strenuous, unless a man has the time to camp out and 
get the whole benefit of the outdoor life of such a trip. 

So-called "Athletics." — The immediate results and the future 
results of competitive athletics is a subject now of wide dis- 
cussion. Even after ordinary competitive exercise, or with 
too rapid training, the individual may become dizzy and fall, 
or he may have palpitation of the heart that may last some 
time. He may be so prostrated that he vomits, and frequently 
albumin and casts appear in the urine after strenuous exercise. 
Acute dilatation of the heart, and rarely death, can occur after 
severe athletic labor. A heart may become dilated to such an 
extent that the individual is prostrated for weeks and perhaps 
months, and he may never again recover his former cardiac 
strength. Any young man who develops, with the amount of 
exercise that his companions can sustain, any of the above 
symptoms should generally be prohibited competitive athletics. 

Before any boy or young man begins training for competitive 
athletics he should be very carefully examined physically, and 
all defects noted, and if he has a disability, all exercise that is 
strenuous should be prohibited. 



688 THE PRINCIPLES OF THERAPEUTICS 

A very important question at the present time is : what is the 
future of individuals who are physically fit, and who stand their 
strenuous athletic work during the athletic age and during the 
period of their severe competition without apparent injury? 
Statistics of insurance companies show that athletes as a class 
have a shorter lease of life than individuals who have not 
been subjected to such strenuous work. They develop cardio- 
vascular and renal disease at a younger age than other men of 
the same class. They are also frequently found to have a 
systolic blood-pressure much higher than normal for their age. 
They all have more or less hypertrophied hearts, which keep 
the blood-pressure high after the strenuosity has ceased, and 
many an athlete immediately feels the loss of exercise when 
he ceases his hard training and begins his life work. Also the 
hearts of athletes, which have been worked to the limit, do not 
as well respond to such emergencies as severe injuries, opera- 
tions, pneumonia, or other serious disease, and such patients 
die of heart failure when theoretically they should survive. 

The drawn, anxious expression, and the fixed contraction of 
the facial muscles of an athlete, while he is at his hardest strain 
or at the end of the period of strenuosity, may be noticed and 
recognized by any observer. This is really the heart strain, 
and the phrase "the heart-breaking" or "the heart-rending 
finish" is a truthful one. 

These are facts and not theories. Therefore physicians 
should use their influence to prevent growing boys and girls 
from taking part in competitive athletics that require enormous 
strain. This does not apply to baseball, and may not apply to 
short runs; it certainly does apply to football in growing 
boys, and applies to basketball in growing girls, and may apply 
to almost any exercise, if participated in too long or too 
strenuously. 

Competitive athletics in our universities undoubtedly does 
an enormous amount of harm to the very best of our coming 
citizens. It is only the most physically fit that are selected for 
competitive athletics, and they are urged by every method 
known to the athletic clubs of the university, and by the 
ordinary human spirit of the desire to win, and by the depend- 



PHYSICAL EXERCISE 689 

ence of the university upon them to win, to exert themselves 
to their utmost limit, to their future, if not their immediate, 
undoing. If these selected individuals become ill during their 
training, they are rarely allowed a sufficient convalescence, 
but as soon as they are partially physically able, are rushed 
again to their strenuous labor. If such individuals use a 
large amount of tobacco, they have one more handicap in this 
cardiac strain that they must undergo. 

Besides the actual strain on the heart and arteries, the 
aortic valve may become diseased by actual physical injury 
through the increased aortic pressure, and narrowing of this 
valve is not infrequent early in life in these athletes. 

The serious injuries that may occur from football in the way 
of fractures, ankle sprains, shoulder dislocations, and injuries 
to knees, some of them perhaps permanent, to say nothing of the 
damaged eyes, torn ears, broken noses, or perhaps some abdom- 
inal injury, are so frequent that but little notice is taken of 
them. Occasionally concussion of the brain, or hemorrhage 
into the brain, or broken necks and broken backs are the out- 
come of this game that, even with the present modification 
of the rules, is altogether too strenuous for tolerance by a 
thinking people. 

In endeavoring to prevent heart strain in young college 
athletes, it should be considered that a mile is long enough for 
the freshman boat race, and that two miles, or at the most, 
three, is long enough for the " varsity" boat race. 

Exercises for Diseased Conditions. — The proper training, 
or retraining, of muscles whose function is impaired, whether 
due to cerebral paralysis, to poliomyelitis, to locomotor ataxia, 
or to any other serious nerve and muscle disease, is an import- 
ant study, and the good results obtained by such training is 
recognized by all specialists in nervous diseases and by all 
orthopedists. 

Graded exercises should be a part of the treatment of circula- 
tory weakness, whether due to heart disease, to obesity, or to 
some other cause. These graded exercises have been termed the 
Schott system and the Oertel system of treatment. A part of 

the well established notoriety of the Nauheim treatment of 

44 



69O THE PRINCIPLES OF THERAPEUTICS 

heart disease is due to the graded exercises there outlined by- 
Professor Schott. These treatments are combined more or 
less with baths, with a rigid, carefully selected diet, and with 
forced rest periods. In heart defects the exercise begins with 
walking, and is gradually graded until hill-climbing and gym- 
nastic work is done. All exercise is carefully supervised by 
the physician in charge, and if dyspnea is caused, or any other 
bad symptoms occur, the exercise is curtailed until such work 
can be done without undesirable symptoms. 

The exercise used to diminish obesity is more strenuous, 
and to be successful it must be combined with a modified diet 
and, generally, with baths. 

There are a great many so-called sanatoria for the more stren- 
uous fads to reduce weight and to improve heart strength. Some 
accomplish a great deal of good; others exist for commercial 
reasons only. However, it should be recognized that strenuous 
exercises, whether advised by book or by correspondence, 
should not be undertaken unless a physician sanctions it after 
a careful physical examination. Serious harm can be done by 
exercise of any and all kinds. 

While deep breathing exercises are of great value in developing 
the chest, much harm can be done by deep breathing and forced 
expansion in pulmonary tuberculosis. Too much exercise of 
a lung can open up healing, contracting areas in the lungs, 
increase absorption of toxins from the tubercles, may cause 
hemorrhage, and often promotes coughing. Such breathing 
exercises are of value, if graded, only after the lung lesions 
are completely healed, to regain the best possible lung capacity. 
Sometimes gentle prolonged inspiration (but not too deep or 
to the point of forced expansion) for a short time is beneficial 
by controllng the tendency to cough. Frequently it is the 
prolonged expiration that increases the irritable non-productive 
(without expectoration) cough. 

REST CURE 

This is often termed the Weir Mitchell treatment. Dr. S. 
Weir Mitchell, who died not long ago well along in honored 
years, was one of the most able clinicians that America has pro- 



:rest cure 691 

duced and also a very noted novelist. He instituted the "rest 
cure" for the treatment of "nervous prostration/' now termed 
neurasthenia. The term neurasthenia has been used to desig- 
nate a more or less constant condition of depression, with the 
sensation of fatigue and exhaustion after even ordinary mental 
or physical exertion. Before a diagnosis of neurasthenia is 
made physical causes for the debility must be eliminated. 

The cause of neurasthenia is not very evident, but there is 
always a lack of circulatory tone, due to a small heart; to an 
insufficiency of the suprarenal glands, as there is constantly too 
low blood-pressure and lack of vaso-motor tone; or to imperfect 
activities of other endocrine glands. The least exertion by such 
an individual often causes the heart to become rapid; or he may 
be sleepy while sitting up and sleepless on lying down, a condi- 
tion that has been termed "vaso-motor ataxia," i.e., erratic 
blood-pressure conditions. 

A brief resume of the physiology of muscle and nerve activity 
may not be amiss in understanding fatigue and the necessity 
for rest. Muscles need much more blood during exercise than 
when at rest, consequently, when a muscle is in action its blood- 
vessels are dilated. When the whole body is active, the abdom- 
inal vessels contract so that more blood is sent by the heart to 
the lungs, to the nerve centers, and to the muscles. More car- 
bon dioxide is produced by muscle activity, and respirations are 
increased to increase the exchange of this substance for oxygen. 
More heat is produced in the body, and this warmer blood may 
increase the activity of the heart, and more heat is lost to the 
body by increased respiration and by perspiration. In strenuous 
exercise, if an insufficient amount of oxygen reaches the muscles, 
more lactic acid is produced, and it may appear in the urine. 

When effort is sustained without intermittent contractions, 
as in pulling or lifting, respiration is temporarily slowed, possi- 
bly momentarily stopped, and the heart is also slowed. The 
blood is thus forced to the muscles that are straining. After 
the effort is over, the blood rushes back to the lungs and abdo- 
men, and the blood-pressure is lowered. This same kind of 
muscular effort occurs during defecation and during such efforts 
as parturition. 



692 THE PRINCIPLES OF THERAPEUTICS 

If the individual is in normal health, moderate exercise will raise 
the blood-pressure, but such increased pressure quickly returns to 
normal after the exercise ceases. If the individual is not strong, 
the increase of bood-pressure develops more slowly during exer- 
cise, but after the exercise ceases, it may be sustained for a time. 

During the activity of the muscle its glycogen is burned to 
water and carbon dioxide, also acid phosphates are formed. 
The increased salts require plenty of water and good circulation 
to remove them to the excretory organs and for them to be 
rapidly excreted. Until these fatigue substances are removed 
from muscles they may ache, or at least their strength is not 
normal, and a feeling of general fatigue is experienced. 

Nervous activity also causes chemical changes, with perhaps 
more or less production of acid products. If these products are 
not rapidly removed by normal circulation, nerve tire is caused, 
possibly neuralgias, restlessness, and irritability. Rest, both 
physical and mental, and especially sleep, allows the nerve tis- 
sues to become normally alkaline and the chromatin substances 
of the nerve cells to be increased in amount. Obviously, if 
some nervous irritation occurs, or if some nervous stimulant, 
caffeine or other, is taken just before the individual is to rest, 
the nerve cells may continue to be irritated, good sleep is not 
produced, brain rest does not occur, and the individual is fa- 
tigued and tired on rising. Or, from disturbed or insufficient 
circulation, or because of the absorption of some toxins from the 
intestine that are irritants to the brain, he may have a more or 
less chronic nervous irritability or chronic nervous tire, and be 
termed neurasthenic. 

It should be recognized that it requires energy and force to 
keep the blood and lymph in the upper part of the body nor- 
mally distributed when the individual is erect. Hence to rest, 
he must lie flat, when the energy needed for normal circulation, 
both of lymph and blood, is the least. Therefore, in weakness, 
the patient must frequently rest lying down. Also in debili- 
tating climates the afternoon siesta is needed, and does not 
necessarily represent laziness. After severe exertion, a short 
period of absolute rest causes recuperation much more rapidly 
than if the individual remains either on his feet, or sits. Chil- 



REST CURE 693 

dren need more rest than adults; consequently school hours 
should not be long, and no single exercise or mental work should 
be long continued. 

The blood-pressure fluctuates daily, being low in the morning, 
and this is one of the reasons why most adults like the morning 
coffee brace. If an individual is shocked, or in pain, or fright- 
ened, the suprarenals are apparently disturbed, the abdominal 
vessels dilate, and he feels faint, especially if he is in the erect 
position. Such an individual should lie down, perhaps logi- 
cally with the feet elevated, and as soon as an increased amount 
of blood flows to the brain and medullary centers, the faintness 
will disappear. Circulatory stimulants produce the same bene- 
ficial effect. 

Excitement, mental work, and worry, are now known to be 
causes of increased blood-pressure. Therefore when the pres- 
sure is too high, the patient's life must be modified, if possible, 
as treatments to reduce high pressure are of little avail, if such 
irritants are continued. 

The importance of rest in serious illness cannot be too much 
emphasized. It is inexcusable to disturb a typhoid patient, for 
instance, every two or three hours during the night for some- 
thing, whether it is for cold sponging, for food, for medicine, or 
for any other cause. The let-alone treatment (unless there is 
some emergency) of patients during the night should be the rule. 
This is not to say that the patient may not be aroused once or 
twice for needed attention, or if he is restless or sleepless, that 
some necessary treatment should not be given him, but to delib- 
erately arouse a quietly sleeping patient because it is time for 
something, is inexcusable. 

The object of the rest cure, then, is to tone up the individual, 
give him mental and physical rest, and at the same time increase 
his nutrition and improve his metabolism. It may not be de- 
sirable for a patient to add weight, consequently the rest cure is 
not always advisable, even if apparently needed, when there is 
obesity. On the other hand, for individuals who are thin and 
underweight, and especially for those who have lost abdominal 
fat and have visceroptosis, an increase of weight, and of fat in 
the abdomen especially, is essential and desirable. 



694 THE PRINCIPLES OF THERAPEUTICS 

The rest cure means, besides rest, regulated food and passive 
exercise, and to be of value the treatment must last from six 
weeks to two months. The patient should be placed in a cheer- 
ful, sunlit room, generally isolated from his or her family, to 
remove entirely, in the first place too much sympathy, and in 
the next place any home irritation that may be present. It is 
essential to have the patient's mind become more or less apa- 
thetic and indifferent to worries and frets of all kinds, i.e., it is just 
as essential to have mental rest as it is to have physical rest. 
For mental rest, the selection of the nurse is important. Nurses 
for neurasthenic, hysterical, or other rest cure patients must 
be especially adapted to this kind of nursing. They must be 
cheerful, efficient, attending to every need of the patient but 
not fussy, too busy, or over-attentive to his every whim. They 
must know how to attend to real discomforts and to minimize — 
without antagonizing the patient — unimportant discomforts or 
supposed discomforts. 

The physician who has charge of a sanatorium for such pa- 
tients must be positive and magnetic, besides being well, strong, 
and cheerful. He must entirely dissociate financial gain to his 
sanatorium (and it is only in sanatoria that such rest cures are 
well carried out) from the medical care of the patient. The 
medical necessity and the therapeutic object should decide 
how long a patient should remain, and iwhat the treatment 
should be. 

In the next place, a patient should not be sent to such a sana- 
torium, if there are any conditions that need special attention, 
surgical or other, unless this sanatorium also is equipped (as it 
really should be) to make all necessary x-ray, blood and excre- 
tion examinations to aid in the decision as to whether this pa- 
tient needs the rest cure and does not need some more radical 
treatment. 

One of the primary objects of the rest cure was what is termed 
"forced feeding," to make the patient gain weight. This is, of 
course, often essential; but since we have discovered that forced 
feeding sometimes prevents improvement, and that less food is 
really needed in many instances, forced feeding is not as fre- 
quently advised. On the other hand, there is a tendency in 



REST CURE 695 

some sanatoria to under-feed, or to limit the food to the no-meat 
fad. The elimination of animal proteins may be advisable; but 
a sanatorium that is noted for feeding all patients alike on a defi- 
nite food plan should not receive all kinds of patients. Patients 
should be sent to such a sanatorium only with a distinct object, 
that object including the kind of food for which the sanatorium 
is noted. The regular and extra meals should be given at regu- 
lar intervals, the exercise and amusements should be at re- 
gular times, and in fact, the whole life of the patient should be 
regulated. 

The object of passive exercise is to prevent loss of muscle 
nutrition and muscle strength, and to increase peripheral circu- 
lation, and for this object massage and electricity should be used. 
The various physical therapies should be used for these patients 
whenever indicated, hydrotherapeutic or other,and if a physical 
treatment will ameliorate a local condition it should be used 
rather than to resort to drugs. 

Modified rest cures may be given at the patient's home, by 
an increased amount of daily rest. The patient may take off 
his clothing and go to bed for several hours in the afternoon, or 
go to bed very early at night, or go to bed before the evening 
meal, or not arise until after breakfast. This extra rest should 
be combined with increased frequency of meals, massage, and 
any other treatment that seems advisable. These patients, as 
well as the patients who are taking the complete rest cure, 
should, at the end of the cure, gradually exercise, first by sitting 
up longer, then walking about the house, then walking out-of- 
doors, then doing some work, until they gradually return to 
their normal life. 

If a patient has a disturbed metabolism, it is wise at first 
to put him on a pure milk diet, until he has eliminated all 
possible food toxins, and then to gradually return to a mixed 
diet. Coffee and tea stimulation should generally be avoided, 
and strychnine should not be given. An increased amount of 
calcium often is needed by these patients, and it may be given 
either in the form of calcium glycerophosphate, as lime water, 
or, if well digested, as an increased amount of milk. Calcium 
often quiets nervous irritability, and an increased amount of 



696 THE PRINCIPLES OF THERAPEUTICS 

it is especially valuable in the rest cure of Graves' disease, and 
patients who have hyperthyroidism should not be allowed meat, 
coffee or tea. 

Many rest cure patients require iron, but the dose should 
be small. If the circulation is sluggish, digitalis may be of 
benefit, but often it is inadvisable; the rest and massage will 
generally improve the circulation. Some glandular treatment 
may be what the patient needs; in fact, many neurasthenic and 
so-called hysterical and neurotic patients are suffering from 
disturbances of the endocrine glands, and the diagnosis is now 
often made of "polyglandular disturbance." The study of 
patients from the endocrine gland standpoint is an art that 
should be cultivated by all physicians, and especially by 
sanatorium physicians. 

Most patients who require a rest cure are constipated. 
Abdominal massage and various other physical methods are of 
benefit, but sometimes laxatives must be given for a time. 
Laxative foods are, however, the best method of treating this 
condition. Agar-agar preparations, bananas, etc., may prevent 
the necessity of drugs. The now popular mineral oil may be of 
advantage for a time in softening the stools ; but it should also 
be recognized that it does not promote digestion, and may 
hinder it. It is possible that occasionally a saline cathartic 
may be needed; it should not be often repeated. The best 
simple laxatives are senna, cascara and aloin. However, as 
above stated, the necessity for the administration of laxatives 
should be regretted, and the intestines should be taught to 
act regularly by habit and by proper food. 

The production of sleep is sometimes the most difficult indi- 
cation to meet. Various physical, especially hydro therapeutic, 
measures should be tried before resort to drugs is made. If 
there is considerable cerebral excitement, for a time bromides 
may be of great help, but they do not promote nutrition, and 
they interfere with the general health. Sodium barbituric acid 
(veronal-sodium) in doses of 0.20 to 0.25 Gm. (3 to 4 grains), 
given a few hours before it is desired that the patient sleep, may 
be necessary for a time; but hypnotics should not be long 
given, and the patient should soon be broken of the habit. 



REST CURE 697 

Some simple cereal food at bedtime may aid in producing sleep. 
Heat to the abdomen, warmth to the feet, and giving the 
patient an extra pillow may all aid in causing sleep. 

The diagnosis of hysteria probably means, very frequently 
the inability of the physician to determine what ails the patient. 
There is generally some functional disturbance which causes 
real symptoms in our hysterical patients, often some glandular 
disturbance, most frequently of the thyroid. Hysterical 
conditions can generally be dissociated from neurasthenic 
conditions, but sometimes the conditions are associated. 
While neurasthenic patients are markedly benefited by the 
rest cure, hysterical patients may become more introspective 
and greater invalids, and acquire the. sanatorium habit. 

For a rest cure to be of benefit to a hysterical patient, she 
must be under the care of a forceful physician, and under 
the care of a nurse with a large amount of common sense, and 
while every disturbed function is righted, if possible, the 
patient should be treated psycho-therapeutically. While the 
mental attitude of these patients is awry, as just stated, there is 
frequently endocrine disturbance present, and perhaps gener- 
ally of the glands that are associated with the sexual functions. 

The so-called Christian Scientist has not discovered a new 
therapy. Mental cures, and cures by mental impression are as 
old as the world, and unusual treatments, unusual methods, 
unusual apparatus, unusual sanatoriums, and unusual distances 
to go for treatment will all impress these patients, and many 
times aid in the cure of the mental part of the disease. 

The need for physical and mental rest for patients who have 
become heart- and brain-weary should be taught the general 
public. Neither the patient nor his family should think that 
because he senses his heart for the first time, and because he is 
found to have heart weakness, and must have a rest, that he has 
heart disease, or that he must die because his heart is disturbed. 
Also, both the patient and his family should understand that 
the brain may become weary, like any other part of the body. 
Hence if he becomes mentally a little warped, and gives evidence 
of some mental peculiarities, and has signs of brain tire and his 
physician advises a complete mental rest, it is no reason for 



698 THE PRINCIPLES OF THERAPEUTICS 

thinking that he is partially insane, or that he will become in- 
sane, or that he always will be "queer." 

If a patient has signs of mental derangement, or even shows 
some symptoms of insanity, it is rarely justifiable to send him 
immediately to an insane asylum. There should be developed 
in every city psychopathic wards in the hospitals for the treat- 
ment of these mentally sick patients. Many a patient will 
completely recover, and he need not then return to his home and 
to his work with the stigma of having been an inmate of an in- 
sane asylum. Many a patient whose brain is not apparently 
working along normal lines will become mentally normal under 
the rest cure and the proper treatment of his physical debilities. 

The value of rest in preventing serious developments in simple 

infections, and in preventing infection in simple injuries should 

be recognized and utilized. Also persistent fatigue removes the 

normal immunity and the normal ability of the individual to 

prevent and combat infection, and also allows heart tire and 

kidney irritation from the accumulation of the waste products 

of metabolism. 

CLIMATE 

The study of the benefits obtained from a change of climate 
becomes more important each year as the systemic changes 
caused by different climates are better understood. Also the 
accessibility of regions once considered remote, and the develop- 
ment of hotels and sanatoria, for the comfort and care of individ- 
uals who are sick and of those who need a "rest cure," have 
made it possible to send patients to regions which were pre- 
viously unavailable. 

A discussion of the climate means a comparison of the tem- 
perature, the moisture, and the altitude. The latitude more or 
less constantly determines the temperature; the altitude not 
only more or less determines the temperature but also the dry- 
ness of the atmosphere, and the purity of the air. The moisture 
is determined not only by rain and melting snow, but also by the 
proximity of bodies of water. Pure, clean air may be obtained 
at even slight elevations, provided that the air is not contamina- 
ted by the dirt and dust of cities and towns. A region that is 
subject to frequent high winds is objectionable, although a hotel, 



CLIMATE 699 

sanatorium or other building may be so located and so protected 
against the prevailing high winds as to make the region available 
for a health resort. However, it is unwise to send an individual 
who needs a change of climate where he will be exposed to 
strong and cold winds every time that he leaves his sanatorium 
or hotel. 

Dust from germ-laden streets; smoke and dust from the burn- 
ing of soft coal; noxious vapors from the burning of any coal; 
leaking illuminating gas pipes; and vapors from factories where 
chemicals are used are all recognized as subjects for sanitary 
science to abolish, if possible. It is also recognized that stag- 
nant air and vapors from low lands, and emanations from stag- 
nant waters (to say nothing of the opportunity for the production 
of mosquitoes) are unheal thful, and individuals breathing such 
an atmosphere are liable to illness, and if ill must be removed to 
more healthful regions to promote recovery. 

Most individuals residing in cities and towns, to-day, have 
more or less irritation of the mucous membranes of the nose, 
throat, and often larynx and bronchial tubes, because of the 
irritant dust which they must inhale. The irritants are largely 
sharp particles from cement or other hard roads, or the particles 
of dried oil, where roads have been made dustless by applica- 
tions of crude mineral oil. Also the emanations from this crude 
oil causes irritation of the upper air passages. The exhaust 
from the poor gasoline burned in motor cars pollutes the atmos- 
phere and causes irritation when inhaled. The result of these 
constantly repeated irritants is more or less increased mucus in 
the upper air passages, or actual catarrh. 

It is obvious, then, that removal to any location that has a 
clean pure atmosphere must be advantageous for any individual, 
well or sick. 

Ocean air contains elements that inland air does not, and per- 
haps one of the principal differences is an increased amount of 
iodine, and iodine is needed by the human body and is more or less 
stimulant. Ocean air is always clean and dustless, although at 
times it is loaded with humidity. Generally on clear days the 
wind will blow on the coast toward the land, a sea breeze, while 
generally at night the wind will blow toward the sea, a land 



700 THE PRINCIPLES OF THERAPEUTICS 

breeze. The climate is that of a low altitude, i.e., sea level. 
Ocean air may be obtained at any seacoast, on islands, and on 
ocean voyages. The temperature of the ocean climate of 
course depends upon the latitude, but islands even in the tropi- 
cal regions may not be uncomfortably hot in summer. Some of 
the islands of the West Indies, especially Jamaica and Porto 
Rico, as well as the Bahamas and Bermudas, are especially 
pleasant resorts in winter. 

Inland climates vary not only with the latitude, but also as 
to altitude. The latitude will determine the prevailing temper- 
ature, and the region will determine whether there is much or 
little moisture. The altitude, varying many thousand feet, 
will determine the temperature and also the dryness. From 
one to three thousand feet high is generally considered to be a 
medium altitude; over three thousand feet is termed high 
altitude, and, from the standpoint of benefit to one who is 
sick, above six thousand feet should rarely be considered for 
a health resort. 

From three thousand feet upwards, the circulation is at first 
much disturbed in most individuals, and one who is ill ordinarily 
cannot tolerate the height of altitude above the sea which a well 
individual can. As we increase the altitude the atmospheric 
pressure is lowered, and the blood-pressure is lowered unless the 
cold is sufficiently intense to cause contraction of the surface 
vessels and thus counteract the lowering of pressure. The 
heart and the respiration become more rapid as the oxygen 
exchange becomes disturbed by the high altitude. The 
peripheral blood shows an increase in the red blood corpuscles 
(nature rushing more into the general circulation on account 
of the oxygen shortage) and the rapid breathing is to cause 
the necessary oxygenation. The least exertion causes an 
increase in the heart rate, an increase in the respiration, and 
a feeling of dyspnea. After a quiet sojourn at an altitude that 
is at first disturbing to an individual, he may acquire a tolerance, 
and his heart and respiration become normal under a normal 
amount of exercise, although exertion may still disturb him. 

The circulatory disturbance caused should preclude an indi- 
vidual with a very high or with a very low blood-pressure, 



CLIMATE 70I 

or with a weak heart, or with valvular disease (even with 
good compensation) from going to these altitudes. Indi- 
viduals who have a tendency to hemorrhage from any part 
should not ordinarily go to an altitude over three thousand feet. 
Tuberculous patients with a tendency to hemoptysis should 
not travel rapidly to a higher altitude, if it is well for them to 
go to a high altitude at all. If it is desired for them to have that 
kind of a climatic change, they may sojourn for a time at a 
medium altitude, and later go higher. 

Many patients are made very nervous and irritable after a 
short sojourn in a high altitude, even though they remain there 
but a few hours. This nervousness lasts for hours or for 
several days. Sometimes when the sojourn is longer at a 
high altitude, on returning to a lower altitude, the individual 
may be excessively nervous and irritable for many days. 
High altitudes, therefore, are not conducive to sleep, unless the 
individual remains long enough to become used to the conditions. 
The cold of a high altitude is also very stimulating, which, 
while perhaps of advantage in low blood-pressure, is a distinct 
disadvantage in high blood-pressure, and in nervous tension. 
A patient who has a simple catarrhal condition of the nose and 
throat may be benefited by this dry, high air, but if he has 
nasal obstruction, or cannot breathe well through his nostrils, 
he will not do well at a high altitude. 

A cold mountainous climate will interfere with the functions 
of the skin, and for this reason patients who have chronic 
nephritis, or even a tendency to imperfect action of the kidneys, 
should not be subjected to the cold of a high altitude, and 
should not be sent to a cold climate. Also patients who have 
gout, arthritis, or neuritis should not go to a cold climate. 
Tuberculous patients who react well to cold, and feel stimulated 
by cold, those who have profuse expectoration, and those who 
have night sweats, are quite generally benefited by a moun- 
tainous climate. 

An inland climate may be dry, even if not very high, as 
we have the desert air of New Mexico and Arizona. South- 
ern Florida has a low altitude, is warm, is likely to be moist, 
and is enervating and not stimulating as are either the high 



702 THE PRINCIPLES OF THERAPEUTICS 

altitudes or the dry climates. Southern California represents 
several types of climates, as a dry, cold atmosphere may be 
found on the high hills, but down near the coast the atmosphere 
is more or less moist, and is especially unpleasant during the 
wet season. However, for a large part of the year, Southern 
California is an ideal climate, without any marked changes. 
Northern California is likely to be cold; though warm in the 
daytime, it is cold at night. 

Some of the resorts in Southern California are not necessarily 
low; for instance, Riverside is 850 feet above the sea level; 
Redlands 1350 feet; Pasadena 900 feet, although Pasadena is 
only about ten miles from Los Angeles, which is close to the 
Pacific Ocean. San Diego is a very popular resort, as is also 
San Bernardino. Monrovia, which is noted for its sanatorium 
for tuberculosis, is 1000 feet above sea level. Other resorts 
of California are the Santa Barbara region, the Catalina 
Islands, and Coronado Beach. 

The high mountainous climates are well represented by vari- 
ous places in Colorado, the Adirondacks, the Allegheny Moun- 
tains, and various other mountainous regions of the United 
States. Dry climates are always more or less stimulating, and 
the high and dry regions especially have that effect. 

The Atlantic ocean resorts of the United States extend from 
Maine to Florida ; the northern shore resorts are popular in the 
summer, and the southern shore resorts in the winter. The 
water on the Maine coast is generally too cold for bathing, 
even in summer. Atlantic City represents a midway resort 
which is popular all the year, and its boardwalk is noted 
for its freedom from all dust. The hotels on the boardwalk 
are also free from dust. The most popular southern ocean 
region is Southern Florida, and especially Ormond. The island 
resorts on the coast are Block Island, Nantucket, Martha's 
Vineyard at the end of Long Island Sound; the ocean side of 
Long Island; and, farther south, the Bahamas and the Bermu- 
das. There are also popular shore resorts for summer all along 
the New Jersey coast. 

The lake regions furnish water resorts. The Great Lakes 
are popular for the middle west, and the St. Lawrence regions of 



CLIMATE 703 

Canada, as well as the lake and mountain regions of western 
Canada are all popular health and recreation resorts during the 
summer. 

The hill climates are well represented by the Berkshire region 
in Western Massachusetts, parts of Maine, the White Moun- 
tains in New Hampshire, the mountain regions of Vermont, 
the Catskills and Adirondacks of New York, the Alleghenys of 
Western Pennsylvania, the Blue Mountains of West Virgina, 
the Rocky Mountain regions, and parts of Colorado. 

The driest atmosphere in the United States is found in New 
Mexico, Arizona, and Colorado. Phoenix, Arizona, a little over 
a thousand feet high, represents a very dry, favorable climate 
for tuberculous patients. Tucson, Arizona has an altitude of 
2,400 feet. Some resorts of Arizona, and El Paso, Texas, have 
an altitude of about 7,000 feet. The Department of the Navy 
has sanatoria for its tuberculous sailors and marines in New 
Mexico and Colorado, while the Army has a sanatorium for its 
tuberculous soldiers in New Mexico. 

Asheville, N. C, has an elevation of 2,250 feet, and is a resort 
especially for the cure of tuberculosis. Pinehurst, N. C. is a 
very popular mid-winter resort for northerners, who do not 
wish the relaxation of the Florida climate. 

The rules that should be followed for sending a patient to a 
different climate are: (1) Has any acute condition the patient 
may have been cured or eradicated? (2) Has operative help 
been given for any disease or condition that may be causing 
symptoms, such as nasal obstruction, suppurating ears, sinus 
disease, infected tonsils, infected teeth, chronic appendicitis, 
gall-bladder disease, etc.? While it may not be advisable to 
remove all of these disturbances before the patient is sent away, 
still the decision, with any of these conditions present, must be 
made deliberately. (3) The patient must have the pecuniary 
ability to go to the region selected and to remain long enough 
for him to receive benefit. (4) The place to which the patient 
is to be sent must offer the comforts needed in his particular 
case; he should not be subjected to hardship unless that is 
deemed advisable for his condition. (5) He must be willing to 
leave his home and cooperate with his physician in establishing 



704 THE PRINCIPLES OF THERAPEUTICS 

his health. (6) The patient to be sent must not be the type 
that is always so homesick and depressed, when away from home, 
as to lose his appetite and not be able to sleep. 

All of these considerations are necessary when the decision 
is made as to whether or not a patient shall be sent away, to 
what place, and how far. It is rarely advisable to send a patient 
away who is really too ill to travel. He may be sent on a 
stretcher to his home, but to send a patient on a stretcher or on 
a bed for a climatic change is inexcusable, except in rare 
instances. 

Patients who are suffering from the following diseases are 
those who are most benefited by a change of climate: hay fever; 
asthma; emphysema; chronic bronchitis; tuberculosis; too high 
blood-pressure; too low blood-pressure; chronic disease of the 
heart; chronic disease of the kidneys; gout; chronic arthritis; 
neurasthenic conditions; and neurotic conditions. 

A hay fever patient may require local treatment of the nose, 
and may have the disease prevented by pollen injections ; but if the 
disease is incurable, he should be sent to a region where there is but 
little vegetation during the season in which his disturbance 
occurs. He may do well on an island, as Block Island; he may 
do well high up in the mountains ; he may do well on a sea-coast 
where there is little vegetation; he very generally does well on 
a sea voyage, if that is within his ability to enjoy. Some- 
times the cedar regions of mountains will at least prevent second- 
ary catarrhal conditions in these patients. Many of these 
patients are benefited by most any change in climate, provided 
they do not go to a region that is loaded with the pollen of plants 
to which they are susceptible. 

The asthma patient should be much more carefully studied 
than the hay fever patient as to local and systemic causes of his 
condition. There is no excuse for sending an asthma patient 
away who carries a removable cause of his asthma with him. 
Asthma patients may be improved at high altitudes, or they may 
be better at low altitudes ; they may be better inland ; they may be 
better on the coast. It is frequently impossible to decide which 
region is the best for a given asthmatic patient; some patients 
are benefited by any change. There is a large nervous ele- 



CLIMATE 705 

ment in asthmatic patients, and anything that interests them, 
or that detracts them from home frets, often causes improve- 
ment. Also, as recognized by us all, many sufferers from 
asthma are not benefited by anything that we can do for them. 

Emphysema is not improved by a high altitude. An emphy- 
sematous patient is the most comfortable in a dry climate at a low 
altitude. A patient with chronic bronchitis is often better in 
the mountains, and he does especially well in dry climates, and 
where there is a minumum of dust. 

Tuberculous patients must be carefully studied to decide to 
which climate or region it is best to send them. Generally they 
should not be sent too far away, as it is best for them to recover 
in the region in which they are to live for the rest of their lives. 
A patient who gets well of his tuberculosis in a very different 
climate than that of his home and then returns home many times 
has relapses. The place for a tuberculous patient is a region 
somewhat elevated, dust-free, with plenty of sun, good food, 
and where it is restful and cheerful. The heart and circulation 
must be especially well studied in these patients before they are 
subjected to either severe cold, high altitude, or long journeys. 

High blood-pressure patients should rarely be sent to high 
altitudes, although they may do well in regions of a thousand 
feet above sea level. They should not be sent where it is cold, 
and they generally feel best at low altitudes and in warm cli- 
mates. The same is true of patients who have nephritis or 
diabetes. Low altitudes are also best for patients who have 
chronic heart disease, although in cardiac weakness and with 
low blood-pressure, the stimulant effect of mild cold and of 
medium altitude, as one or two thousand feet, may be of 
benefit. 

Patients with gout, chronic arthritis, or neuritis should go 
where the climate is warm and dry. They generally do best 
where the sanatorium is associated with medicinal springs, where 
they are put on a rigid diet and eliminative treatment, with 
more or less local treatments of the joints and nerves, but a 
warm, dry and low altitude region is best for these patients. 

Neurasthenic patients are best at a low altitude, and in warm 

regions, not hot enough to be relaxing or depressing, in a region 

45 



706 THE PRINCIPLES OF THERAPEUTICS 

similar to Southern California. Neurotic patients and sleepless 

patients should generally not be sent to mountainous regions. 

They may do well in Florida, and they may be improved by 

most any kind of sanatorium treatment. A few may be cured by 

a mountainous climate, and by being subjected to simplicity and 

some hardship. 

MINERAL SPRINGS 

To be termed a mineral spring, the water should contain a 
tangible amount of mineral matter, and it is thought that the 
amount should be at least 5 grains of the more common salts 
per gallon. 

Although artificial mineral waters are readily prepared by 
following the analyses of the spring waters, still it must be 
granted that the springs cannot be absolutely duplicated. 
Mineral waters mostly contain radio-active substances which 
are absent when they are artificially produced. Waters that 
contain considerable amounts of carbon dioxide may be dupli- 
cated in this respect by charging the artificial water, but even 
with this refinement of duplication mineral waters made 
artificially cannot have and do not have quite the effect of the 
natural waters. Rather than to attempt to duplicate a mineral 
water, it is better to give the drugs for which the water is noted 
by means of prescriptions. 

Bottled spring waters drunk at the individual's home, also, 
cannot have quite the efficacy of the same waters drunk at the 
springs, except possibly the cathartic waters and pure drinking 
waters, such as Vichy and Kissingen water, i.e., the table 
waters. We cannot dissociate from mineral water treatments 
the good done by the regime of regulated diet, exercise, baths, 
etc., instituted at the mineral spring hotels and sanatoria. 
There is also a change of climate for the patient and there is 
the psychic effect of being away from business and home duties, 
and " taking a cure," and this mental effect is exceedingly 
valuable in any treatment of chronic conditions. We cannot 
well duplicate the waters that are naturally warm or hot at the 
springs; and as above stated, we must now recognize the effect 
for good of drinking radium waters, and of baths taken in 
radio-active waters. 



MINERAL SPRINGS 707 

The amount of water that a given individual should drink is 
a subject for study, and cannot be decided without deliberation. 
The individual may require more water, or less, depending upon 
his condition, but it should be recognized that plenty of good 
drinking water does not interfere with digestion, but, on the 
contrary, promotes it. The more the exercise, the more water 
needed. The more the toxemia from mal-digestion, from 
bad food, or from poor metabolism, the more the water needed. 
The more salts received into the body, whether by food or 
medicine, the more the water needed for their proper excretion. 
On the other hand, a patient with poor circulation, with even 
slight edema, or with insufficient kidneys should not drink 
large amounts of water. When a patient must arise several 
times at night to urinate, such a patient should not take much 
water before going to bed. Patients who have diabetes in 
any form, those who perspire very profusely, and those who 
have suffered severe hemorrhage, should take plenty of water. 

A glass of ordinary water or a laxative water taken before 
breakfast is of advantage in constipation. If there is inflamma- 
tion of the stomach, or even if there is only an increased secre- 
tion of mucus, a glass of hot water taken half an hour or an hour 
before meals is of advantage in washing off the mucus and sooth- 
ing and cleansing the membrane. Also water is a stimulant to 
the outpouring of the gastric juice. Hot water is generally 
quickly passed into the intestines, and cold water remains in 
the stomach but a short time. Iced water or excessively cold 
water should not be drunk in large amount with a meal, but as 
above stated, water at ordinary temperatures is an aid to diges- 
tion when taken with meals. 

A patient who shows a tendency to deposit salts, or to form 
concretions in the gall-bladder, in the kidneys, or in the joints, 
should drink more water, and best a distilled water. A mineral 
water that is well charged with salts may not be of benefit to 
him, and may actually be harmful to him. Distilled water 
will prevent deposits and aid in eliminating salts from the 
body more than waters that contain large amounts of salts. 
Very few mineral waters are really diuretic; they cause diuresis 
for the simple reason that larger amounts of water are taken. 



708 THE PRINCIPLES OF THERAPEUTICS 

The cathartic waters may cause some diuresis, if they are not 
taken in large enough amounts to cause purging. A solvent 
effect from lithium waters is a myth; they cannot and do not 
cause any such action. If they contain but few salts and are 
taken in large amounts, they act simply as any other water in 
diluting the secretions and excretions of the body. 

It has not been exactly decided why, in certain small regions 
in this country, the women, and sometimes the men, are likely 
to develop goiter. The water in these regions is generally 
loaded with lime, and is a "hard" water. Women, especially, 
going to these regions should drink distilled water or some 
bottled water; or, if they drink the water of the region, it should 
be boiled. Why boiling the water renders it less likely to 
cause goiter has not been decided, as germs causative of goiter 
have not been discovered in these waters. The boiling may 
precipitate some of the salts and thus prevent them from being 
ingested, and consequently some chemical disturbance of the 
thyroid gland be prevented. 

Classes of Springs. — Spring waters may be classed as: hot, 
carbonated, alkaline, acid, cathartic, calcium, iron, sulphur, 
arsenic, and lithium. The hot springs, or thermal springs as 
they are termed, generally contain carbon dioxide gas, and 
often hydrogen sulphide gas, as well as small amounts of other 
gases. Obviously, the hot waters can only be utilized at the 
springs. 

The most popular hot springs in the United States are the 
White Sulphur Springs of West Virginia, and the Hot Springs 
of Arkansas. On the western coast the hot sulphur springs of 
Pasa Robles are very popular. The sulphur springs of Mt. 
Clements in Michigan are much frequented. Other hot 
springs of the United States are located in Arizona, Colorado, 
New Mexico, South Dakota, and in the Yellowstone Park. 

The natural carbonated springs furnish the waters that are the 
pleasantest for drinking purposes. Many of the spring waters, 
however, are charged artificially, either at the spring or during 
bottling for transportation. The Kissingen Springs of Saratoga 
furnish an acid drinking water; they have no special medicinal 
effect. 



MINERAL SPRINGS 709 

The alkaline waters, especially when made sparkling, make 
the best, most soothing table waters. These are the vichy 
waters, notably those of Saratoga. One of the most popular 
waters in this country for drinking purposes is the White Rock. 
There is no necessity for importing Apolonaris water when 
such satisfactory national spring waters are obtainable. 

The cathartic springs contain several laxative salts in vary- 
ing amounts, notably sodium sulphate and magnesium sulphate. 
Some of the best cathartic waters of this country are obtained 
at Saratoga, and are the Congress water and the Hathorn water. 
The Glenwood Springs in Colorado produce laxative waters. 
The sulphur waters are also cathartic, and some of these springs 
contain magnesium sulphate. Most of the sulphur springs 
contain calcium, often in the form of calcium sulphate, notably 
the springs at Clifton and Richfield, New York. 

The waters that contain large amounts of calcium are all 
"hard" waters, and are not much used for medicinal purposes, 
although they may be of value in chronic diarrhea and in 
tuberculosis. The iron waters are more or less constipating, 
and are of value in anemia, but probably of no more value than 
is the administration of any inorganic iron. Very many springs 
contain small amounts of iron, but the springs of Bedford, Pa. 
are well known as iron springs. 

The water of the arsenic springs, which are few in number, 
should not be taken without the advice and care of a physician. 

The Hthium waters are listed last, because as "lithium 
waters" they are unimportant. Many of the lithium springs 
furnish fine water for drinking purposes, notably the Poland 
Springs of Maine, but, as previously stated, there is no solvent 
effect from lithium salts on kidney or other calculi. The only 
advantage obtained by individuals who drink Hthium waters 
for this purpose, or for an excess of uric acid, is that they drink 
large amounts of water and also generally adopt a diet that is 
beneficial. 

The diseases most benefited by sojourns at medicinal springs 
are such chronic diseases as arthritis and gout; some chronic 
diseases of the skin; such chronic poisonings as occur after the 
proper treatment of syphilis; chronic malarial poisoning; 



7IO THE PRINCIPLES OF THERAPEUTICS 

chronic lead poisoning; such disturbances of metabolism as 
are evidenced by deposits of bile or urinary salts; so-called uric 
acid conditions; plethora; and obesity. Any patient who is 
neurasthenic or is debilitated, or is convalescent from some 
serious illness may be benefited by a sojourn at a sanatorium 
located at a mineral spring. Such patients should generally 
take only the tonic waters. 

Rheumatic and syphilitic patients are most frequently bene- 
fited at the sulphur springs. Part of such improvement is 
probably psychic, due to the individual's enduring the odors of 
the sulphur gas. 

At most of these spring resorts various hydrotherapeutic 
measures, electric treatments, massage, vibrations, sunlight, 
violet ray, and sun lamp treatments are given, and most 
individuals who are not hopelessly diseased will be benefited, 
provided that focal infection is not neglected, and that neces- 
sary surgical procedures are not omitted. Those who are 
financially able to enjoy treatment at such luxurious resorts 
should be encouraged to seek the benefits offered. Unfortu- 
nately, the large majority of those who are sick must be treated 
at home by adopting the best methods possible. 

The detail of the regime and the various " cures" need not be 
here given, as they vary somewhat at the different springs and 
for the object for which the treatment is given. It should be 
recognized that America can doubtless furnish as efficient 
treatment at its medicinal springs as is offered in Europe. Of 
course the farther the individual travels, and the more rigid 
the regime which he is willing to adopt, the greater the impres- 
sion made on his mind; and the more that he is subjected to 
radio-active water treatments and unique methods of treat- 
ment, the more he will improve. Psychotherapy is closely 
associated with every kind of therapy, and there is always a 
profound mental effect from the treatment at medicinal 
springs. 



PART IX 

CHRONIC DRUG POISONING 

ALCOHOL 

General Considerations. — There is doubtless an inherited 
desire of the nervous system for stimulation, and there may- 
be an inherited desire for alcohol. There seems to be no 
question that if one or both parents of a child are alcoholics 
the child does not inherit a normal withstand power against 
disease or against abnormal cravings, perhaps a lipoid disturb- 
ance. Some individuals have a very strong desire for sugar, 
and eat one or more pounds of candy at a time, especially on 
certain days. This same individual with another environment 
drinks alcohol to excess. The over-smoker sometimes has 
a desire for alcohol; and anything that diminishes an alcoholic's 
control, as over-smoking will do, makes him desire and crave, 
and acquire, if he can, an over-amount of alcohol. Towns 
has found that a cured case of delirium tremens or acute 
alcoholism remains longer cured, if he will stop his smoking. 

With prohibition it is a question whether the individual, 
who has this strong desire for alcohol will get and take some 
other drug, or whether he will become a hard smoker, or an 
excessive eater of sugar, or an excessive drinker of coffee or 
tea. At any rate, he is likely to develop some abnormal 
excessive habit. The advantage of prohibition is that the 
young individual cannot well acquire the taste or desire for 
alcohol. The future lessening of crime by prohibition that 
prohibits cannot at the present time be forecasted. 

The only proper place to treat acute alcoholism in any form 
is in an institution, or in a hospital with a special private ward, 
with the patient under the care of a physician who understands 
the treatment of this kind of poisoning. 

Delirium Tremens. — The new prohibition laws must make 
the frequency of delirium tremens much less than formerly, 

711 



712 THE PRINCIPLES OF THERAPEUTICS 

although the seriousness of the condition, when it develops, 
is likely to be greater on account of the individual having 
often obtained a poor quality of alcohol, if not wood alcohol. 

Those who are wont to take alcohol in large doses more or 
less continuously are likely to develop signs of delirium tremens, 
or at least considerable cerebral irritation and meningismus, 
when they suffer from acute infection, more especially if that 
infection is pneumonia. As delirium tremens has seemed to be 
caused by a sudden privation of the alcohol to which an indi- 
vidual was accustomed, it has seemed wise, when a patient 
became seriously ill and had the history of regularly taking 
alcohol in considerable amount, to continue small doses 
of alcohol during his illness rather than to deprive him of that 
drug. 

The individual who goes, or did go, on periodic drinking 
bouts caused by some systemic or nervous craving which has 
not been well understood, is likely to have an aftermath of very 
serious nervous disturbance and perhaps delirium tremens. 
This condition is always preceded by entire loss of appetite, 
with nausea and vomiting perhaps, and a general irritated 
condition of the nervous system, and not infrequently a mild 
acidosis due to privation of food, although alcohol more or 
less inhibits that condition. 

These periodic debauch attacks should be considered a 
disease, and the individual should be treated as one who has a 
disease and not as a criminal. When such a patient has the 
first indications of his coming torment and craving desire for 
alcohol, he should be taught to immediately report to his 
physician and be confined for a time, if necessary, or at any 
rate receive such nervous sedatives as will tide over this periodic 
nervous condition. Unfortunately, such an individual can 
probably even yet, and for some time to come, obtain some 
form of alcohol to start his debauch, whether a patent medicine, 
hard cider, or some liquor or wine. 

As above stated, delirium tremens seems to develop from 
privation of alcohol in one who is in the midst of its need, 
and a man on a debauch may develop delirium tremens, if his 
stomach refuses to retain the alcohol that he can get; or if he 



ALCOHOL POISONING 713 

has gotten considerable and can get no more, he is likely to have 
delirium tremens. These patients are always sleepless, which 
soon adds to their intense nervous excitement. Sooner or later 
delusions occur, and they see things and hear things, and may 
become almost actively insane. As an aid to the diagnosis that 
the cerebral excitement of the patient is due to privation of 
alcohol it may be noted that tremor is generally a symptom of 
that condition. 

The delirium tremens patient does not need alcohol for its 
stimulating effect, but he needs it for its narcotic effect, and 
the narcotic effect of alcohol should never be forgotten. This 
is frequently overlooked, and those who decry the use of alcohol 
medicinally for any condition whatever overlook the fact that 
in some individuals the narcotic effect of alcohol is valuable. 

Towns, who has made a study of drug addictions, including 
alcohol, states that a patient who can sleep will not have de- 
lirium tremens. Therefore he urges that all alcoholic patients 
should be put to sleep. Also he thinks that it makes no differ- 
ence for how long a period the individual may have been drink- 
ing hard, he should not be immediately deprived of alcohol. 
Therefore, the treatment of delirium tremens and of chronic 
alcoholism at the Towns Hospital in New York is alcohol and a 
sedative, as chloral hydrate. He also finds that free catharsi s 
promotes recovery. 

Treatment. — The first thing to do is to wash out the patient 's 
stomach, to prevent further absorption of alcohol. Then, as 
soon as the stomach has rested for a short time, other treat- 
ments must be inaugurated. With the first indication of 
cerebral disturbance in an alcoholic, the patient should receive 
some cathartic, as calomel, 0.20 or 0.25 Gm. (3 or 4 grains) with 
sodium bicarbonate 1 Gm. (15 grains). At the same time of 
administering the calomel it is well to give a compound aloin 
tablet, both of these cathartics acting in about the same length 
of time. If the calomel does not act efficiently in six or seven 
hours, the contents of a bottle of effervescing citrate of magne- 
sium should be given. 

As soon after the cathartic has been given as seems advisable, 
the patient should receive 2 Gm. (30 grains) of sodium bromide, 



714 THE PRINCIPLES OF THERAPEUTICS 

in plenty of water. This may be repeated in four hours, if the 
patient does not sleep. As soon as the cathartic has acted, and 
before, if the patient shows signs of delirium, chloral hydrate 
should be given in a dose of i Gm. (15 grains) and repeated in 
one or two hours, if needed. No other hypnotic is as valuable, 
although paraldehyde has been much lauded, and at times may 
be given in teaspoonful doses on cracked ice and water. The 
action of paraldehyde is very rapid, but unless the dose is 
sufficient, it may have no action whatever, and if the dose is 
sufficient it may cause depression. 

It should be noted, as Towns urges, that after delirium tre- 
mens has thoroughly developed hypnotics are always more or 
less dangerous, as they are likely to cause depression, and with 
delirium tremens there may be cardiac depression at any time. 
Therefore, with this condition, and especially when drugs are 
given by the mouth, there may be non-absorption for hours and 
then, through some physiologic or chemical change, the patient 
suddenly absorbs all the doses he has in the stomach and in- 
testines and develops a cumulative effect. Therefore, poison- 
ous amounts of narcotics should never be given. Consequently 
in such conditions it is sometimes safer to administer scopola- 
mine hydrobromide, hypodermatically, combined,if the pulse 
seems to require it, with digitalis. The scopolamine may be 
repeated in one or two hours, if needed. Occasionally a 
patient has an idiosyncrasy against scopolamine and atropine in 
any form, and excitement is caused rather than a quieting effect. 
If such an idiosyncrasy is known, of course the scopolamine 
should not be used. 

Ergot is of value in any condition of cerebral excitement, and 
especially with so-called wet brain. In delirium tremens ergot 
is safe and of great value, and will accentuate and prolong the 
action of any narcotic or nerve sedative and, at the same time, 
it improves the circulation. Ergot for this purpose should be 
administered intramuscularly, and the best aseptic prepara- 
tions, representing the whole drug, should be used. 1 mil (15 
minims) should be injected into the deltoid muscle, to be re- 
peated in two or three hours if necessary; it may be given two or 
three times in the following twenty-four hours, if advisable. 



ALCOHOL POISONING 715 

If the heart is acting badly, and the pulse is very irregular, 
weak, and rapid, and yet it seems advisable to administer a 
hypnotic, morphine may be given hypodermatically, as mor- 
phine does not depress the heart, but the dose must be fairly 
large, else this drug will add excitement to the already excited 
brain. It should, however, be constantly remembered that the 
delirium tremens patient must sleep, else he will not recover. 
Of course, if it is possible to wait, it is inadvisable to administer 
morphine until after the cathartic has acted. 

If the circulation is failing it may be taken for granted there 
will be very little absorption of any medicament given by the 
stomach, as the stomach is more or less inactive and the con- 
tents will not be absorbed or passed into the duodenum for ab- 
sorption there. This is the reason that when there is a sudden 
evacuation of drugs from the stomach into the intestine some- 
times a cumulative action from them occurs, consequently large 
doses of digitalis (often advised) by the mouth are inexcusable. 
The best circulatory stimulant in this condition is ergot, given 
intramuscularly. Atropine and strychnine are the next best 
stimulants, but both are likely to increase nervous irritability, 
and hence should generally be withheld. 

If there are symptoms of cerebral edema and stupor, with low 
blood-pressure and failing heart, no treatment is better than 
ergot intramuscularly, and, if necessary, strophanthin intra- 
venously or intramuscularly. It may also be wise to give a 
colon injection of sodium bicarbonate solution to aid in pre- 
venting acidosis. Also glucose solutions injected into the colon 
may improve the condition. 

If the feet are cold and there is subnormal temperature, the 
patient should be surrounded with dry heat; hot water bags at 
his feet, and warm alcohol rubbing will bring more blood to the 
surface of the body and relieve the cerebral congestion. 

A patient under treatment for acute alcoholism should never 
be left alone until he is quietly sleeping and the pulse is good, 
and even then his condition should be frequently noted. 

As soon as the patient awakes from a good sleep, some simple 
warm starch nutriment should be given. These patients are 
likely not to have eaten anything of importance for hours, and 



716 THE PRINCIPLES OF THERAPEUTICS 

perhaps for several days, and acidosis readily develops. Well 
sweetened lemonade to which has been added an alkali, as 
sodium citrate, and whiskey or other alcohol if deemed 
necessary, should be frequently given, the alcohol being omitted 
as soon as it is thought advisable. 

Lumbar Puncture. — The relation of the cerebrospinal fluid 
to delirium tremens has been studied, and, many times, in these 
conditions it has been found to be increased. Therefore spinal 
puncture and the withdrawal of a small amount of fluid if the 
tension was increased is logical treatment. At times spinal 
puncture, especially when done early, has decidedly shortened 
the duration of the delirium and of the symptoms of cerebral 
alcoholism. It may be that the ventricular fluid contains an 
irritant to the brain,' and if the pressure is high removal of a 
certain portion of this fluid may be beneficial by removing so 
much of the irritant. If the pressure in the cerebrospinal canal 
is low, it may be well to withdraw a small amount of fluid and 
inject a physiologic saline solution to dilute the irritant. With 
high pressure more fluid could be withdrawn and then physio- 
logic saline solution injected, much as is done in the spinal serum 
treatment in epidemic meningitis. More scientific research 
along this line is advisable, as it is not clear just what the 
pathology is in alcoholic delirium. 

MORPHINE HABIT 

Owing to the strenuousity of our lives and to the ease, in 
spite of the Harrison Law, with which morphine and heroin can 
be obtained, these habits have been on the increase. Now, 
with the prohibition laws more or less preventing the use of 
alcohol, narcotic addicts, or, at least, addicts to some drug, are 
more likely to increase in number. 

There is a constant desire in mankind in civilized regions, 
and especially in the strenuous conditions of the world during 
the last few years, both for things that stimulate and for things 
that quiet, i.e., narcotics. Morphine and heroin are stimulants 
to those who are used to them, provided the dose is not too large; 
secondarily they are narcotics. There is even a habit for qui- 
nine, for aspirin, and for coal-tar products, the quinine because 



MORPHINE HABIT 717 

it stimulates, and the aspirin and coal-tar products because 
they quiet pain and irritability. 

Before the Harrison Law prevented the duplication of pre- 
scriptions that contained morphine, it was estimated that a 
little more than 50 per cent, of morphine addictions occurred 
on account of physicians' prescriptions being repeated. At the 
present time a patient who becomes an addict must obtain his 
drug in some other way than by the prescription of a reputable 
physician. 

It has been estimated that an ordinary individual will be- 
come addicted to opium, or one of its alkaloids, if it has been 
used daily for a month. Many serious conditions in medicine 
may require the use of morphine for that length of time, but it 
obviously is the physician's duty to continue rigid care of that 
patient until the habit has been entirely broken and the craving 
for the drug has ceased. In the vast majority of such cases it 
is unnecessary for the patient to know or realize what drug he is 
taking, or that he has acquired a need for that drug. The 
successful, careful physician can carry such a case to a satisfac- 
tory conclusion without the patient ever knowing that he has 
become used to a narcotic, or needed it. 

In rare instances where there is chronic pain and the disease 
is incurable, there is not only excuse for a morphine or codeine 
habit, but in fact, there is no excuse for withholding such a com- 
fort from an incurable case of pain. However, before it is de- 
cided that such a drug is needed and that the "habit" is neces- 
sary, the physician must have tried every other possible resource, 
as there can be no question that privation from the drug at any 
time after the habit is formed will increase the suffering and 
increase the pain for which the drug was given. Also, unfortu- 
nately, frequently the dose of the narcotic must be gradually 
increased to cause the same therapeutic effect. On the other 
hand, there are many patients who suffer a moderate amount of 
pain, and the disease which causes the pain is incurable, who can 
take a small amount of morphine daily for months and even for 
years without requiring a larger dose. There has lately been 
discovered a substance termed benzyl benzoate which it is hoped 
will have a sedative narcotic effect without causing a habit. 



718 THE PRINCIPLES OF THERAPEUTICS 

The most insidious of the narcotic poisons is heroin, the in- 
troduction of which into medicine was very unfortunate. Heroin 
is absolutely not needed therapeutically, and should never be 
prescribed, and should be abolished from the Pharmacopoeia. 
Heroin has been very readily obtainable by addicts of all 
ages; it is a most demoralizing poison, much more seriou sin its 
results than is morphine. It has been shown that heroin has 
been much more readily obtained in certain regions and locali- 
ties than in others. Statistics 1 show that of 3,208,446 men 
examined by draft boards 2,007 were rejected on account of 
alcohol and drug addiction. 

As individuals used to the alkaloids of opium or heroin can 
withstand enormous doses without poisoning, there must be 
something developed in the system that renders it tolerant to 
these poisons. The immunity acquired must be due to some 
antibody or substance which in privation of the morphine 
causes the individual to suffer all sorts of systemic disturbances, 
from muscle and joint pains to sweatings, digestive disturbances 
diarrhea, cough, cutaneous disturbances, sleeplessness, and even 
delirium. The usual dose of morphine to such an individual 
will immediately stop all of these symptoms; too small a dose 
will only partially stop the symptoms. On the other hand, 
anything that diminishes or washes out this substance (what- 
ever it is) from the blood diminishes the intensity of the symp- 
toms, and a smaller dose of the narcotic drug will then cause 
amelioration of the symptoms. Also, if the drug is opium or one 
of its alkaloids or heroin, atropine in some form is more or less 
of a physiologic antidote. Therefore all successful treatments 
are based on elimination and atropine. Consequently, free 
purging, some form of atropine, and diminishing doses of the 
drug is the most successful and least painful treatment of the 
habit. 

Bluemel 2 makes a suggestion worth serious consideration, 
namely, that whatever it is in the blood that causes the craving 
and the symptoms of privation, or causes the tolerance for enor- 
mous doses, may be diluted in the blood by intravenous infu- 

1 New York Med. Journ., May 3, 1919, p. 777. 

2 Journal A. M. A., Peb. 22, 1919, p. 552. 



MORPHINE HABIT 719 

sions of physiologic saline. Probably this dilution is just what 
occurs with profuse watery purging and the administration of 
plenty of water for the patient to absorb. 

Treatment. — In the first place, rarely can a patient be success- 
fully treated for the morphine, heroin, or cocaine habit without 
he is placed in the proper kind of an institution, and the insti- 
tution must be under the jurisdiction of a medical man who 
thoroughly understands the subject and who has the support of 
a humane staff. In the next place, the patient should be thor- 
oughly examined in every detail, in order to understand his 
physical condition, to ascertain what damage he has received 
from the drug, and to discover any disease from which he may 
be suffering. This means especially a careful urinary examina- 
tion to determine the efficiency of the kidneys; a careful cir- 
culatory examination; and a blood count. Also localized in- 
fections from dirty hypodermic needles should be cleaned up 
before the patient is subjected to active treatment for with- 
drawal of the drug. There also should be noted and eradi- 
cated mouth and tonsil infection, if such is present. If a cure 
is to be made of such patients they must be made well, if 
possible, else if their pain or discomforts again return, they 
will, if they can acquire it, return to the drug. Many of these 
patients are emaciated and have very poor general nutrition. 
They may not have been able to obtain food, or to digest it, 
if they have obtained it. It must also be noted that there are 
very many internal glandular disturbances caused by a narcotic 
habit. The thyroid and the suprarenals are greatly disturbed. 
The blood-pressure of these patients is likely to be low, and the 
suprarenals are likely to imperfectly secrete. The thyroid may 
be depressed or excited and is likely to become easily hyperex- 
citable when the drug is withdrawn. 

It may be advisable to push nutrition for some days before 
the treatment of the habit is begun. The symptoms from with- 
drawal are nervousness; sleeplessness; lack of mental concentra- 
tion; more or less lachrymation ; increased secretion of mucous 
membranes; sometimes sneezing; muscle twitchings, perhaps 
cramps; bowel cramps and more or less diarrhea; generally a 
rapid pulse and low blood-pressure; and widely dilated pupils. 



720 THE PRINCIPLES OF THERAPEUTICS 

Before beginning the withdrawal of the drug, a reliable nurse 
must be placed in charge of the patient; there must be no possi- 
bility of his jumping out of a window, and there must be no 
possibility of his obtaining more of the drug than is administered 
to him. Also, there is absolutely no excuse for extreme suffer- 
ing, either mental or physical, and sleep should certainly be 
produced. 

The primary treatment should be a brisk cathartic, and 
calomel, in a good sized dose, combined with bicarbonate of 
sodium and aloin, to be followed in six or seven hours by a saline 
purge to insure free, watery purging, is satisfactory. The 
treatment advised by Sceleth seems to be one of the most 
sensible. After the cathartic the patient is given the following 
mixture : 

Scopolamine hydrobromide 3*1 oo grain 

Pilocarpine hydrochloride 3^2 grain 

Aethylmorphine hydrochloride (dionin) 3^ grain 

Fluidextract cascara sagrada 15 minims. 

Alcohol 35 minims| 

Water up to 1 fluidrachm (60 minims) 

The dose of the above varies with the amount of morphine 
which the patient was taking. When more than 10 grains of 
morphine per day was taken, Sceleth gives 60 minims of the 
combination every three hours, day and night, for six days. 
On the seventh day the dose is reduced to 30 minims; on the 
eighth day to 15 minims; on the ninth day 15 minims three 
times a day instead of every three hours day and night; and 
on the tenth day this treatment is stopped and strychnine 
nitrate Jljo grain three times a day is substituted. On the 
eleventh day the strychnine is reduced to %o grain three times 
a day. This is continued for a week. During the first five 
days he gives a very light diet, but liquids freely. Patients 
who are taking less than ten grains of morphine a day start 
with a dose of 30 minims of the mixture; and if less than 5 
grains, 15 minims. 

This treatment seems to be based on physiologic and drug 
sense. In other words, the aethylmorphine hydrochloride is 
substituted for the morphine; the depression is fought by an 



MORPHINE HABIT 72 1 

atropine antidote, namely, scopolamine hydrobromide ; to 
prevent the drying of secretions by the scopolamine and to 
encourage the promotion of all secretions the pilocarpine is 
given; and the laxative treatment necessary is kept up by the 
cascara sagrada. If the patient is very wakeful it may be 
necessary to substitute or add some sleep-producing drug, as 
chloral. On the fifth day of this treatment the patient is 
generally able to eat, and has lost his severe craving for the 
morphine. 

If the pulse goes below 40 or above 120 per minute Sceleth 
stops the scopolamine mixture, and if there are signs of collapse, 
he would give Ji grain of morphine hypodermatically. What- 
ever the treatment, if collapse develops, a temporary tangible 
dose of the drug to which the patient was addicted must be 
given. Sceleth finds but infrequent atropine delirium from the 
scopolamine in this combination, but of course cases of serious 
idiosyncrasy against atropine in any form must occasionally 
occur. 

As above stated, in the temporary, necessary, production of 
a morphine habit by the physician, in acute conditions, the 
subsequent gradual withdrawal of the drug without the patient 
being aware of his condition or suffering much discomfort is the 
proper treatment. This same gradual reduction process is 
recommended by many clinicians who are experts in the 
treatment of drug addiction. The addict is surrounded with 
the same care as in the more rapid withdrawal treatment, and 
each day he is given a carefully measured smaller dose. The 
accuracy of the measurement of the dose is very important, as 
if a mistake is made and more is given than intended the 
treatment is prolonged, and if the patient is given less on any 
day than is intended, great discomfort is caused, and a larger 
dose must be quickly substituted. In this method of treatment 
other drugs are not needed, but there must be good free bowel 
movements and plenty of food taken, best starches and 
vegetable proteins. 

Pearson 1 who is an advocate of the gradual reduction treat- 
ment and describes the process, finds that four regular doses of 

1 Interstate Medical Journal, Dec, 191 7, p. 1130. 
46 



72 2 THE PRINCIPLES OF THERAPEUTICS 

the morphine a day, one after each meal and one before bedtime, 
are the best intervals for its administration. He urges a very 
gradual diminution of the daily dose, as more rapid diminution 
would defeat its object by causing hardship and compelling the 
increase of dosage. If the patient has been taking very large 
doses, it is not very difficult to reduce the enormous amounts, 
but it must be gradual down to i grain a day, and from i grain 
down to nothing must be very gradual, even to as little as Hoo 
of a grain, or less, four times a day. This small amount seems 
absurd, but as a matter of fact, if water is substituted instead -of 
this small amount, the patient will show symptoms. But long 
before the dosage has ceased, the patient is convalescent, the 
appetite has returned and nutrition is improving. With this 
method of reduction, as Pearson urges, the patient is being 
treated mentally and physically; his morale is encouraged, he 
has not suffered, and he is gaining in health every day. 

Institutional treatment of a patient should not be considered 
complete until his nutrition has improved, and he has had hydro- 
therapy, massage, and finally out-door exercise, and then, if 
there is a diseased condition that has caused him to become an 
addict, this condition should be properly treated. If he cannot 
be cured, and no treatment other than a narcotic gives him 
comfort, he certainly will relapse. 

All these patients need iron, and they may need organic ex- 
tract treatment. Sometimes they develop a very great appe- 
tite, and the amount of food that they take should be regulated. 
All alcohol should be withheld from these morphine addicts, and 
they should be cured of a tobacco habit, as each one of these 
habits stimulates other habits, and the better they are cured of 
all habits, the less likely are they to return to the morphine 

habit. 

COCAINE ADDICTION 

The use of cocaine is becoming less and less frequent as laws 
against obtaining it have been longer in force than those against 
morphine. Often these addicts have the morphine or heroin 
habit combined with the cocaine habit; but the cocaine habit 
is more deplorable than the morphine habit, as the demoraliza- 
tion and the systemic injuries that cocaine causes are greater 



TREATMENT OF DRUG ADDICTS 723 

than those caused by morphine. No patient can take cocaine 
for any great length of time without being seriously injured. 

The treatment for removal of the addiction is by control, 
purging, nutrition, nerve sedatives, and cardiac stimulants, the 
exact method being governed by] the condition of the patient. 

REGULATED TREATMENT OF DRUG ADDICTS 

Theoretically with the long continued action of the Harri- 
son Narcotic Law, drug addicts should become less and less fre- 
quent. Until this sad condition is eradicated, each community 
should appoint a medical member of its health department to 
have charge of all addicts of his locality. This physician should 
be furnished with an institution where these sufferers can be 
properly treated, and no one but this medical appointee or his 
assistant should be authorized to write prescriptions for, or give 
morphine, heroin or cocaine to an addict. If the addict has an 
incurable disease he may be treated regularly by his own physi- 
cian, but, if he is an addict without an incurable serious disease, 
there can be no excuse for not placing him where he can be cured 
of his habit. There is no other good way of treating this kind 
of a patient; office treatment is not justifiable. To promote 
cures and for necessary statistics every case of drug addiction 
should be confidentially reported to the Board of Health or to 
some other properly constituted authority. Records of such 
cases should be protected as strictly confidential and the patient 
should be given a number, and on reports and in correspondence 
he should be known by his number. If he enters the special 
hospital, he should be known to the attendants by number. 

The necessity for Public Health officials to more seriously 
consider the drug addiction question will be shown by a few 
statistics. 

Dr. S. Dana Hubbard 1 shows the magnitude of the traffic in 
narcotic drugs by quoting the following figures: "The average 
yearly consumption of opium for the period from 1910-1915 
was 491,043 pounds, which at the price of $40 a pound would 
make a total value of $18,841,720. The average consumption 
of coca leaves for the same period was 1 ,048,250 pounds. At the 

1 Journal A. M. A., May 22, 1920, p. 1439. 



724 THE PRINCIPLES OF THERAPEUTICS 

present price of $1 a pound this would represent approximately 

$20,000,000." 

He says that it has been estimated that "about 90 per cent, of 
the opium and cocaine imported is used for other than medicinal 
purposes; and 80 per cent, of the addicts visiting the New York 
Department of Health Clinic are young men and women just 
out of their teens. " 

Hubbard thinks that no less than half of the addicts can be 
brought back to useful lives, and he states that "bad associates 
and evil environments are the chief causes in producing addic- 
tion among youthful habitues in New York". The record for 
that city is probably not different from that of other cities. 
This opinion is shown to be correct by the Riverside Hospital 
(North Brothers Island, N. Y.) Statistics furnished by T. F. 
Joyce, 1 the physician in charge. He finds that the overwhelm- 
ing majority of these patients come from the under world, 
and largely began to use the drug through association with 
habitues. Predisposing causes of the drug habit he finds to 
be "late hours, dance halls, and unwholesome cabarets," 
especially if the individual is a little subnormal mentally. 

Joyce describes the treatment at this hospital as follows: 
As soon as the individual is admitted, his clothing and belongings 
are removed, and he is given a new outfit, even including 
hospital shoes. He is then taken to a preparatory ward where, 
after a period of six days, the dose of the narcotic is brought 
down to the lowest amount that will prevent the signs of drug 
privation, which is from 2 to 3 grains in twenty-four hours, 
even if the addict has been consuming as much as 20 to 60 
grains of morphine or heroin a day. "Four-fifths of 2,300 
patients treated at the Riverside Hospital were addicted to 
heroin, while about one-fifth was addicted to morphine or 
other form of opium." About 12.5 per cent, of the heroin 
addicts also used cocaine. 

The treatment was catharsis, but not drastic purging, with 

capsules containing calomel, ipecac, rhubarb, atropine, and 

strychnine. The patients were also given saline colonic 

irrigations. Scopolamine hydrobromide is the hypnotic used 

1 New York Medical Journal, Aug. 14, 1920, p. 220. 



TOBACCO HABIT 725 

at this institution, and while this drug is being pushed they do 
not give food, but give large quantities of alkaline waters. 
After the drug of addiction has been completely withdrawn 
and the patient is practically through with his scopolamine 
period, which is in about a week or ten days, he is sent to a 
convalescent ward for physical reconstruction. Later, after 
light exercises, the patients are assigned to some work, under 
the name of " occupational therapy." 

TOBACCO HABIT 

The cigar consumption in the United States has shown some 
decrease in the last three or four years, from over eight billion 
in 191 7 to over seven billion in 191 9. The cigarette consump- 
tion has increased from 8 billion 500 million in 1910 to 46 
billion in 191 9. The use of chewing and smoking tobacco in the 
same time has also increased enormously, more than 400 
million pounds. For the fiscal year of 19 19 the revenue of the 
Government from the tax on tobacco was 206 million dollars. 

According to Professor Henry W. Farnam 1 the amount spent 
on tobacco by the people of the United States in the fiscal year 
of 191 7 was probably not less than $1,200,000,000. For 
comparison of figures, Professor Farnam notes that "the 
value of all metals mined in the United States in 191 5 was 
$992,816,000., while the coal, both hard and soft, mined in 
1 91 5 amounted to $686,691,000, while the cost of building 
operations in fifty-one largest cities of the United States 
in 1916 was $780,183,000.; the total cost of education including 
the common schools, universities, etc., in 1916 was $914,804,000. ; 
and the expenditure on highways in 1916 was $290,000,000.; 
the toal receipts from passenger service on railroads, including 
parlor cars, in 191 6 was $652,027,000." 

Farnam notes that Great Britian consumed, the year before 
the war, 2.09 pounds of tobacco per capita to our consumption 
of 5.57 per capita. Therefore, if we should be satisfied with the 
amount of tobacco with which Great Britian is satisfied per 
capita, we would reduce our tobacco bill by $720,000,000. In 
other words, if we used no more tobacco than Great Britian 

1 The Investment Weekly, March 2,3, 1918, p. 18. 



726 THE PRINCIPLES OF THERAPEUTICS 

used, we could have duplicated in two years nearly all the 
buildings built in the fifty-one largest cities of the United 
States, or we could have added 80 per cent, to our expenditure 
on education, to say nothing of the loss of efficiency by very 
many of our working men of all ages through the excessive 
use of tobacco. Professor Farnam also notes that if we had 
used the amount that we paid for tobacco more than Great 
Britian, we could have given some education to a large part 
of the 5,500,000 illiterates shown to be in this country in 1 918. 
To put it another way, Professor Farnam some years ago 
estimated that the amount paid by tobacco users in this country 
was annually about three times the entire cost of the Panama 
Canal. 

The fire cost in the United States from careless smokers is 
simply tremendous, and the ones most careless with lighted 
matches and lighted tobacco are the cigarette smokers. 

The fine sense of courtesy and thoughtfulness for others 
seems frequently to be lost by even the best of men who smoke 
excessively, and such defects are particularly noticeable in the 
cigarette smoker. If not prohibited, the latter will invade 
every apartment and compartment, public or private, with his 
cigarette and its fumes, generally purely thoughtless and not 
meaning to be discourteous. 

The loss of efficiency in mental and manual work is very 
great in those who over -smoke, and the loss of mental efficiency 
by young growing boys who smoke cigarettes has long been 
demonstrated, and is a positive fact. It has also been dem- 
onstrated that a large number of delinquent boys and boys who 
reach the courts through misbehavior are largely cigarette 
smokers. Also many cigarette fiends become later "dope" 
fiends, and young men who were wont to take too much alcohol 
were also frequently very hard smokers, mostly of cigarettes. 
In other words, the use of tobacco in young boys and the over -use 
in young men is conducive to bad morals in all lines, and the 
greatest disturbance to mental efficiency seems to occur in those 
who use cigarettes. 

In all training for athletics tobacco is withheld from the par- 
ticipants by the trainers. In spite of this fact, our soldiers in 



TOBACCO HABIT 727 

training were urged to smoke, and largely to use cigarettes, by 
every means known, namely, by association, by example, by 
Red Cross gifts, by other free gifts, and by charitable funds of 
all kinds. The soldiers were then trained intensively and were 
subjected, in France, many times to severe hardship, both 
mental and physical. Physically, excessive use of tobacco 
could only unfit them, and mentally, it might modify nervous 
strain; but the action of tobacco on the heart muscle could be 
nothing but a disadvantage, and in some soldiers, who had 
irritable hearts and hearts that became rapid on the least exer- 
tion, the disability could be traced to tobacco. Also, in the 
French and English hospitals where soldiers were recovering 
from serious wounds, they were urged by all visitors, if not 
actually by those who were caring for them, to smoke cigarettes, 
and not a few surgeons objected to this on the ground that over- 
smoking would interfere with their recovery. 

Action. — When tobacco is smoked by one who is not used to 
it, it causes more or less nausea and depression, and lowering of 
the blood-pressure. If enough has been taken, there may be 
depression, cold perspiration, faintness, vomiting, and even 
collapse. If the use of tobacco is persisted in, a tolerance 
develops, and these unpleasant symptoms do not occur. 

Acute nicotine poisoning can cause death, and the treat- 
ment of such poisoning is dry heat, and strychnine, atropine and 
caffeine hypodermatically. Probably nicotine causes depres- 
sion of the suprarenals, consequently injections of suprarenal 
are indicated. 

Chronic Poisoning. — One who is used to the action of tobacco 
has his blood-pressure raised during smoking, and the in- 
creased pressure continues for a longer or shorter time, depending 
on the individual and the condition of his arteries and heart. 
He is, also, mentally quieted, if he is nervous, by the narcotic 
effect of the tobacco. His brain may act better temporarily, 
and he may think better by the increased pressure causing more 
blood to go to the brain, provided that he has long used tobacco 
and is not smoking to excess. How much tobacco is excessive 
depends entirely on the individual. One cigar, or three or four 
cigarettes, may be too much for one person, while five or six 



728 THE PRINCIPLES OF THERAPEUTICS 

cigars, or twenty to thirty cigarettes, a day may be tolerated 
by another. 

The most frequent symptoms of over-action of tobacco are 
throat catarrh, laryngeal inflammation, and lingual tonsil con- 
gestion, with, often, a dry, tickling cough, and more or less 
mucous or mucopurulent secretion causing expectoration. The 
next most frequent symptoms of its over-action are hyperchlor- 
hydria and slight gastric disturbances with more or less indi- 
gestion. Other symptoms are increased rapidity of the heart, 
occurring with the least exertion, or even slight palpitation at 
any time; sharp, momentary cardiac pains; a tendency to per- 
spire freely, especially the hands; and sometimes cold hands and 
feet. There may be muscle and joint pains, and headache is 
not infrequent. There may be contracted pupils, and some 
disturbance of vision at times. Still greater poisoning is shown 
by a lowered blood-pressure and a weakening of the cardiac 
muscle. Sometimes with excessive smoking, especially if as- 
sociated, as it sometimes is, with too much drinking of coffee, 
the nervous system is irritated, and the patient is sleepless and 
irritable. Besides 'the action of tobacco on the blood-pressure, 
which is more or less constant, tobacco increases peristalsis, 
and those who suddenly stop the use of it are generally con- 
stipated. Tobacco is excreted by the kidneys, saliva, and 
perspiration, and one who is constantly smoking actually reeks 
of tobacco. 1 

One's circulation may be affected by tobacco if he simply sits 
in a room where there is tobacco smoke. Therefore an in- 
dividual smoking in a room with others smoking, or in a 
smoking car, or breathing smoke or tobacco emanations in a 
room where he is working, gets a great deal more tobacco than 
he believes he is taking. For this reason more tobacco can 
be tolerated in the open air than indoors. Individuals with 
high blood-pressure increase this pressure by their tobacco, 
unless the heart has begun to fail. Consequently, in treating 
hypertension, besides stopping tea, coffee, and too much meat, 
and regulating the patient's life, tobacco should generally be 
entirely withheld. 

The smoking of a single cigarette by an habitual smoker wall 






TOBACCO HABIT 729 

raise the pulse rate and increase the blood-pressure, but one 
who is used to much smoking cannot as well sustain exertion as 
one who is not saturated with tobacco, even if his blood-pressure 
is normal and his heart apparently normal. He becomes 
breathless on exertion as compared with the man who is not 
saturated with tobacco. Especially dangerous, often, is 
tobacco when a patient has had anginal attacks, due to coronary 
disease. 

To repeat, the most serious disturbance caused by the over- 
use of tobacco is on the heart, and while smoking may tempo- 
rarily slow the pulse, if fast, soon, with a weak heart, the 
rapidity is increased, and very soon the rapid heart action is 
frequent, and although while smoking the blood-pressure may 
be increased, with excessive use it is soon diminished. The 
heart may be irregular or intermittent, and there may be 
actual dilatation of the heart and an insufficiency of the mitral 
valve, entirely due to the over-use and over-action of tobacco. 
Tobacco heart is a recognized condition which can generally 
be cured by withholding tobacco. 

Whether the adverse action of tobacco on the heart rhythm is 
due to vagus disturbance or due to disturbance of the coronary 
circulation, or whether due to both, has not been determined, 
probably both actions occur. It has not been shown that 
sclerosis of the coronary arteries is due to tobacco, but certainly 
disturbed circulation in the coronary arteries is suggested when 
anginal attacks occurring after the excessive use of tobacco 
entirely disappear after the tobacco is withheld. Also it would 
be hard to prove that actual degeneration of the heart muscle 
is due to tobacco, there being so many other associated disturb- 
ances occurring in the patient that could be causes of that 
condition. However, dilatation of the heart from tobacco does 
occur. 

Whenever it is decided that a patient is using too much 
tobacco, it should generally be immediately stopped. If the 
patient is nervous, he should receive a few doses of a bromide. 
If he craves something in his mouth, he may use chewing gum, 
or dissolve a Jio grain quinine tablet in his mouth as often 
as he feels the desire to smoke. Digitalis is often indicated 



730 THE PRINCIPLES OE THERAPEUTICS 

when the heart muscle shows weakness, and if it is dilated. 
When a large user of tobacco has a serious illness, and an 
irregular action of the heart and almost heart failure develops, 
he should be urged to smoke half a cigarette at a time, three 
or four times in twenty-four hours. Sometimes a heart so 
disturbed will be steadied by such treatment better than by 
any other medication. During the prostration of acute illness 
is no time to stop a drug habit, and tobacco is a drug and is 
frequently indicated in serious illness and especially in the 
convalescence of constant users of tobacco. 

If an individual must smoke, the time to smoke is after 
meals and not before meals, and certainly not before breakfast. 






PART X 
INDUSTRIAL POISONING 

Preventive medicine is perhaps the most important study 
of the age. Sanitation, care of epidemics, isolation of infec- 
tions, and the prevention of poisoning and of injuries are sub- 
divisions of this great work. In this section it is aimed to 
describe the treatment of the chronic poisonings that occur 
among the artizans of some of the industries. 

The most frequent of these poisonings occur from lead, but 
not infrequently poisoning occurs from phosphorus, zinc, mer- 
cury, arsenic, hydrofluoric acid, uranium, manganese, and from 
aniline in the manufacture and handling of dye stuffs. 

Mercury poisoning can occur in workman who make thermom- 
eters, and it occurs occasionally in the felt hat industry. The 
principal symptoms are tremors, ulcerations, salivation and 
digestive disturbances. 

Arsenic poisoning is not now very frequent, but may occur 
from the fumes in some steel industries. 

Hydrofluoric acid poisoning occurs among glass workers, and 
the symptoms are ulcerations of the skin and mucous mem- 
branes. 

Uranium poisoning occurs from the dust of uranium oxide, 
which when swallowed into the stomach is dissolved and ab- 
sorbed. After absorption uranium is a poison to the kidneys, 
causing nephritis. Uranium salts are poisonous, and there is 
absolutely no excuse for uranium as a drug, and the uranium 
nitrate of the Pharmacopoeia should be dropped from the next 
revision. 

Manganese poisoning may occur among those who work in 
manganese dioxide. The symptoms of such poisoning are las- 
situde, drowsiness, muscle twitchings or cramps, and more or 
less mental and spinal depression. The condition is serious, 
and such poisoning must be prevented. 

731 



732 THE PRINCIPLES OF THERAPEUTICS 

Investigations of the cotton mill industries have shown that 
the death-rate is very much greater than among other individ- 
uals of the same class in the same climate, and that the hazard 
from tuberculosis in cotton mill workers is excessive. Women 
operatives show a higher death-rate than men operatives in 

this industry. 

LEAD POISONING 

Most any salt of lead may cause poisoning, but perhaps the 
suboxide is the most dangerous of the salts that are used in the 
industries. This salt forms on the surface of molten lead and 
is given off in fumes, if the temperature is high enough ; also this 
salt is the most frequent cause of poisoning in those who are sub- 
jected to the vapor of lead or those who directly handle lead 
as type setters, plumbers, and moulders. Oxide of lead, lith- 
arge, is another frequent cause of poisoning, as well as are the 
red leads and the carbonate of lead, white lead. These salts of 
lead are more likely to cause poisoning in painters and in those 
who lead carriage or automoblie surfaces and then rub them 
down. 

Plumbi Acetas, {Lead Acetate; Sugar of Lead). — An official 
preparation of lead acetate is Liquor Plumbi Subacetatis, which 
contains both lead acetate and lead oxide, so-called Goulard's 
Extract. From this preparation is made the official Liquor 
Plumbi Subacetatis Dilutus, which preparation is entirely un- 
necessary. The stronger preparation may be used, in solutions 
containing 5 to 10 per cent., externally as a sedative astringent, 
provided there are no abrasions of the skin and no possibility 
of absorption. It is not often that this preparation is needed. 

There is no excuse for using lead in any form internally, 
therefore a dose for lead acetate is superfluous. 

Plumbi Oxidum, {Lead Oxide; Litharge.) — The official prepara- 
tion of this salt is Emplastrum Plumbi, Lead Plaster (Diachylon 
Plaster). From this plaster is prepared Emplastrum Resince 
(Rosin Plaster, Adhesive Plaster). Also from lead plaster is 
prepared the official Unguentum Diachylon. It is doubtful if 
lead plaster, rosin plaster, or diachylon ointment are needed. 

Toxic Action. — Acute lead poisoning generally occurs only 
from the acetate of lead, and the symptoms are those of a gastro- 



LEAD POISONING 733 

intestinal irritant. When taken into the stomach an albumi- 
nate is soon formed, which is more or less protective to the 
membranes, so that deep ulceration does not occur. However, 
if the dose is sufficient, immediate vomiting occurs, with intense 
pain, followed by collapse, numbness, paralysis, and finally 
coma. Associated symptoms are burning of the throat, a 
sweetish metallic taste, colicky pains, thirst, cramps in the mus- 
cles, then heart weakness, cold extremities, and collapse. As 
the patient rarely dies immediately from this poisoning, the 
urine soon becomes very scanty, later albuminous, and still 
later there is suppression. If the patient survives a day or two 
paralytic symptoms develop, and he may die in coma or 
convulsions. 

Treatment of Acute Poisoning. — If vomiting has not occurred 
the stomach tube should be gently passed and the stomach 
washed out, or a hypodermic of apomorphine may be given. 
Then several doses of sodium or magnesium sulphate should be 
administered, not only to form the sulphide of lead but also to act 
as a cathartic. The subsequent treatment consists of demul- 
cent drinks, drugs to combat collapse, and the administration 
of large amounts of water to relieve the kidneys from irritation. 

Chronic Lead Poisoning. — The name of plumbism has been 
given to chronic poisoning from this metal, which condi- 
tion develops after the long continued introduction of very small 
quantities of lead into the system, apparently always through 
the gastrointestinal tract. Even if the dust or vapor is inhaled, 
the lead is probably swallowed into the stomach and poisoning 
thus occurs. Workers in lead, who are not exposed to vapors and 
dust, swallow the lead with their food from lack of cleanliness. 

Besides the industries that are likely to cause poisoning, 
which have been above mentioned, accidental poisoning not 
infrequently occurs, and in such cases the diagnosis is very 
difficult. Poisoning from drinking water that runs through 
lead pipes does not often occur, but when the pipes are not 
properly filled and air reaches them a carbonate of lead is 
formed. Water running through the pipes, especially if it is 
soft and is not loaded with minerals, picks up some of this 
carbonate and when such water is drunk it will soon produce 



734 TH E PRINCIPLES OF THERAPEUTICS 

chronic poisoning. Lead poisoning has occurred from canned 
goods, but newer methods of canning have minimized this 
possibility. 

It has long been thought that sulphuric acid lemonade taken 
freely by those who worked in the fumes and dust of lead would 
prevent poisoning, but Doctor Alice Hamilton 1 after much in- 
vestigation of the subject, has found that this acid lemonade is 
not a protection against lead poisoning. 

The susceptibility to poisoning by this metal varies greatly, 
some individuals apparently being tolerant to it; others are 
poisoned within a few weeks, and Doctor Hamilton found that 
in some factories from 25 to 35 per cent, of the employees had 
some form of lead poisoning. Negroes are more susceptible to 
lead than white men, and women are more susceptible than men. 
Also, anything that fatigues the patient, or poor hygienic 
surroundings increases the susceptibility to lead poisoning, and 
those who indulge in much alcohol are more susceptible to it. 

It has never been shown that lead poisoning could occur 
through the unbroken skin, but it has always been an interest- 
ing clinical observation that painters may develop wrist-drop, 
caused by a neuritis of the musculospiral nerve. 

Chronic insidious lead poisoning presents multiple symptoms, 
the most frequent perhaps being anemia, either due to the 
action of the albuminate of lead (in which form it is absorbed) 
directly on the red cells, or to action on the red bone-marrow. 
Basophilic granules are frequently found in the red cells in 
lead poisoning. When found present they are very suggestive 
of chronic lead poisoning, but they are not pathognomonic and 
do not always occur in lead poisoning. 

Another frequent symptom of lead poisoning is an increasing 
blood-pressure, probably due to irritation of the lead on the 
blood-vessel walls, which sooner or later causes endarteritis 
and perhaps atheroma. Later the increased pressure is due to 
interstitial nephritis, which is a result of long continued chronic 
lead poisoning. 

Nervous disturbances occur, as cold hands and feet, and 
muscle cramps. There is always more or less constipation, 

1 Journal A. M. A., Sept. 7, 1912, p. 777. 



LEAD POISONING 735 

whether or not there is gastric indigestion, and there is likely to 
be an increased amount of indican in the urine, which is an 
indication that more irritants are acting on the kidneys. 

These patients often have pyorrhea, and there may be a blue 
line at the junction of the gums with the teeth, but this blue 
line is by no means a constant symptom at the present day. 
Generally, careful analysis of a considerable quantity of urine 
will show lead in the urine, although lead poisoning can be pres- 
ent even if lead is not found in the urine. 

Lead colic may occur at any time, or may never occur, in 
patients who have chronic lead poisoning. It may occur 
suddenly, or only after a long period of constipation, and with 
the colic generally occur vomiting, slow pulse, and high 
blood-pressure. 

The treatment of lead colic is a hypodermic injection of 
morphine and atropine ; hot moist applications to the abdomen, 
or if the patient is able he should sit in a hot bath to relax the 
spasm. As soon as he ceases to vomit he should be given large 
doses of sodium sulphate. As this colic may be caused by 
blood-vessel spasm, nitroglycerin (or amyl nitrite) has been 
suggested, to relieve the contraction. Also, chloroform in- 
halations to primary anesthesia will stop the colic. Some of 
the symptoms of chronic lead poisoning and the colic may be 
due to a disturbance of the endocrine glands, especially of the 
suprarenals. The after treatment is the same as that of any 
chronic lead poisoning, but lead colic having once occurred, it is 
likely to recur unless further ingestion of lead is absolutely 
prevented. 

Another frequent form of lead poisoning is that in which the 
nervous system is more affected. There are tremors and 
multiple neuritis, with sometimes paralysis of the extensor 
muscles of the hands and fingers, wrist-drop. The cause of 
this form is a neuritis of the musculospiral nerves. This 
generally begins in the extensors of the third and fourth fingers, 
then the extensors of the little finger, wrist, and thumb are 
affected. Rarely the ulnar and median nerves are involved. 
Generally the wrist-drop is bilateral, but it may be unilateral, 
and not infrequently the right arm is more affected than the 



73^ THE PRINCIPLES OF THERAPEUTICS 

left, in right-handed workers. The lower extremities are rarely 
affected in lead poisoning. 

The pathology of the nerves involved seems to be a neuritis, 
with the motor neurons most affected. Occasionally there are 
anesthesias. Changes have been found in the spinal cord, in the 
anterior horns of gray matter, and in the anterior nerve roots. 
Rarely disturbances of the eyes and loss of vision have occurred, 
and still more rarely pathologic conditions of the brain have 
developed. 

Probably in all chronic poisoning with lead the thyroid is 
more or less injured and its activity decreased. The sexual 
functions are more or less disturbed, and women who work in 
lead are likely to abort, and if the children of such women are 
born, they are frail and likely to die in infancy. 

Treatment of Chronic Lead Poisoning. — The diagnosis of 
lead poisoning having been made, the patient should be removed 
from all possibility of again absorbing the metal, as the individ- 
ual is always more susceptible to the poison after having had 
one attack. The treatment of the general condition is: daily 
free movements of the bowels, caused by sodium sulphate; 
plenty of good food ; iron ; and sodium iodide in small doses, not 
more than 0.20 Gm. (3 grains) two or three times a day. The 
object of the iodide is to render the lead in the tissues more 
soluble and to prepare it for ehmination. For this reason 
large doses of iodide should not be given, lest too much of the 
lead be made soluble at once and acute colic or other symptoms 
of poisoning occur. Daily hot baths are of advantage, to 
make the skin more active, to lower the blood-pressure which 
is generally high, and to improve the surface circulation. If 
the chronic poisoning has proceeded to real cachexia, it may be 
very difficult to bring the patient back to health, and some- 
times an incurable anemia develops. The paralytic symptoms 
should be treated by rest, if there are acutely inflamed nerves, 
and later by proper electrical stimulation and massage to keep 
the muscles from atrophying, during the period in which the 
nerves are incapable of transmitting voluntary impulses. 
Wrist-drop alone is generally curable, but if the paralysis is 
more extensive, recovery may not take place. 



POISONING FROM PAINTS 737 

Lead poisoning should be suspected in any patient whose 
work is associated in any way with the use of lead, if he comes 
with indefinite symptoms and no apparent acute definite 
disease. The symptoms causing the most suspicion are pale- 
ness-, anemia, constipation, a metallic taste, muscle and joint 
pains, and tremors. 

The prevention of chronic lead poisoning from fumes and 
from dust is the duty of the sanitary inspector and the owners 
of the plants. Chronic poisoning from carelessness, due to 
eating when the hands, face and mustache are dirty, or to 
drinking out of dirty, contaminated glasses, is entirely the 
fault of the individual. While lead poisoning possibly can 
occasionally occur from absorption through the external skin, 
it generally occurs by swallowing the lead into the stomach, 
and perhaps, rarely from absorption from the air passages. 

POISONING FROM PAINTS 

An investigation by Harris 1 of the susceptibility of painters 
to lead poisoning showed that a mixture of white lead, linseed 
oil and turpentine forms a particularly dangerous combination, 
and that vapors from this mixture could cause skin irritations, 
nausea, vomiting, headache, conjunctivitis, dizziness, irritation 
of the throat and bronchial tubes, and even faintness and 
strangury. Also when benzene is mixed with paints and the 
vapors are inhaled, nausea, vomiting, and cough may occur, 
and even more serious poisoning. 

Harris found that benzol, acetone, wood alcohol and amyl- 
acetate are the usual ingredients of the varnish- and paint- 
removers employed by painters, and that amylacetate is largely 
used as a vehicle for bronze pigment. Men using these sub- 
stances not only complain of the effects of the fumes, but also 
suffer from skin inflammations. Nearly half of the 402 painters 
examined by Harris showed evidences of some form of lead 
poisoning. Not infrequently painters using these combinations 
of substances are so overcome by the fumes as to become 
dizzy, and even occasionally fall from ladders. The urine was 
always more or less disturbed in these cases, having a strong 

1 Archiv. Int, Med., Aug., 1918, p. 129. 

47 



738 THE PRINCIPLES OF THERAPEUTICS 

odor, a high color, and causing more or less bladder irritation. 
Benzene seemed to be the ingredient of the combination that 
caused the most unpleasant symptoms. 

BRASS FOUNDERS' CHILLS— SPELTER CHILLS 

This poisoning occurs in those who work in brass or zinc 
founderies and are subjected to the vapors from the liquid 
metal. The younger the individual, the more he is susceptible 
to the poison, and women are more susceptible than men, and 
weak men than strong men, and, as with lead poisoning, those 
who use alcohol are more likely to have this form of poisoning. 
The symptoms are not dissimilar to malarial chills, except that 
there may be severe muscle pains, a prickling feeling in the 
throat, cough, and diarrhea. While a sturdy individual may 
withstand several of these chills, if they are repeated he becomes 
more or less incapacitated for work and seems to be predisposed 
to inflammation of the lungs, and especially to tuberculosis. 

The treatment of such a chill consists of hot baths, applica- 
tions of dry heat, and hot drinks of tea or lemonade to promote 
perspiration. If there is depression, hot coffee or caffeine should 
be given. 

The prevention of this disturbance is, again, largely a sani- 
tary problem, and factories should not employ young boys and 
girls, women, or weak, anemic individuals to do this kind of 
work. The individual prevention is, again, cleanliness and the 
removal at night of all garments used during the day, and a fre- 
quent change of undergarments, as the fumes of the poison are 
likely to be contained in the clothing. 

These chills must not be mistaken for malarial chills, and the 
patient be improperly treated with quinine, and the cause of the 
poisoning be allowed to be repeated. Sometimes in such cases 
after repeated attacks paralytic symptoms have occurred, more 
especially a weakening of the legs. Such cases, however, are rare. 

It may be parenthetically stated that there is absolutely no 
excuse for the administration of zinc in any form internally. 

PHOSPHORUS 

The official preparation of this drug is Pilula Phosphori 
(Pills of Phosphorus) . There is no excuse for the drug or its 



PHOSPHORUS POISONING 739 

preparation. Phosphorus as such is not needed in medicine; 
phosphates and glycerophosphates are the phosphorus prepara- 
tions needed. 

Toxic Action. — Acute poisoning from phosphorus is generally 
accidental, due to children eating the heads of matches or to tak- 
ing some rat poison. The fatal dose of phosphorus may not be 
more than 0.05 to 0.10 Gm. (about i to ij^ grains). 

The symptoms of acute phosphorus poisoning are likely to 
develop slowly, especially if there is food in the stomach, and 
sometimes symptoms may not occur for several hours after the 
poison has been ingested. There is a general feeling of nausea 
and weakness, with later vomiting, and the odor of the vomited 
matter is that of phosphorus, or of garlic. Sooner or later 
intense pain develops, although this may not always be an 
important symptom. Occasionally the poisoned individual 
dies early, but generally the symptoms continue for several 
days, and the patient may die after it was thought that he was 
convalescent, due to ulcerations of the stomach or intestines. 
In these, cases of late serious symptoms the liver is always dis- 
turbed and jaundice is likely to develop, often preceded by 
diarrhea with mucus and blood in the stools. Soon cerebral 
symptoms occur, such as delirium, sometimes convulsions, and 
later coma and death. There may be hemorrhages from dif- 
ferent parts of the body, especially from the nose. The urine 
is scanty, contains albumin, and sometimes sugar. If death 
does not occur from such severe poisoning, convalescence is very 
slow. 

Phosphorus poisoning causes fatty degeneration of the liver, 
kidneys, and pancreas, and degeneration of the heart muscle. 
The jaundice may be due to both obstruction of the bile ducts 
and to breaking down of the red blood corpuscles, i.e., it may be 
hematogenous. 

Treatment of Acute Poisoning. — The first treatment is to 
cause vomiting as quickly as possible, and the best emetic for 
this purpose is sulphate of copper. Later the stomach should be 
washed out with large amounts of water, or a i to iooo warm 
potassium permanganate solution, as the danger lies in a piece 
of the phosphorus sticking to the mucous membrane and grad- 



74-0 THE PRINCIPLES OF THERAPEUTICS 

ually causing serious ulceration. Oils should not be given as 
they tend to promote absorption of the phosphorus. Dilute 
peroxide of hydrogen solutions have been suggested with which 
to dislodge the phosphorus and allow it to be vomited or washed 
out of the stomach. 

The subsequent treatment depends entirely upon the condi- 
tion of the patient. Purging with a saline is advisable. 
Collapse must be combated, and the future symptoms watched 
for and treated in the best manner possible. 

Chronic Poisoning. — Those who work in phosphorus are now 
rarely subjected to the fumes, on account of proper sanitary 
precautions, but they are likely to inhale a sufficient amount to 
cause disease of the mouth, especially if there is any exposed 
bone or decayed or ulcerated teeth. Periostitis and necrosis 
of the bone are likely to occur, if such a condition is present. 
Phosphorus may cause salivation. If the fumes of phosphorus 
must be more or less inhaled, masks should be worn to prevent 
the possibility of poisoning in this manner, and all workers in 
phosphorus factories should have their teeth and gums particu- 
larly carefully supervised, as their mouths should be in perfect 
condition. 

POISONING BY DYE-STUFFS 

The opportunity for poisoning from these substances is 
constantly on the increase, and most anilines are poisons. 
Doctor Alice Hamilton 1 has investigated this danger, and finds 
that the dyes are founded upon benzene and its derivatives, and 
the most poisonous substances seem to be benzol, toluol, phenol 
and xylol. She found evidences of the toxic action of these 
substances in the eyes, in the gastrointestinal tract, and in 
the kidneys. Benzol causes destruction of the red and white 
blood cells and is a poison to the central nervous system, and in 
acute poisoning there may be intense cerebral irritation before 
death. There may be hemorrhages, and severe nose-bleed is 
often a beginning symptom. After mild poisoning the individ- 
ual recovers, generally in twenty-four hours, but in severe 
aniline poisoning there may be acute prostration, with very low 

1 Penn. Med. Journ., July, 1919, p. 655. 



TRINITROTOLUENE POISONING 74 1 

blood-pressure and the patient may be unconscious for several 
hours. Sometimes symptoms of aniline poisoning occur after 
the patient has left the factory. There are often chest pains, 
and sometimes eruptions on the skin. 

It has been noted that there is a great difference in the 
susceptibility of patients to aniline poisoning, the same as 
there is to lead and zinc poisoning. Death can occur from 
aniline poisoning. 

The nitrobenzenes have been found to be very poisonous, and 
carelessness in their use may cause vapors that are dangerous. 
Nitrochlorbenzene, which is used in making sulphur dyes, 
Doctor Hamilton found to be the cause of intense itching of the 
skin. Phosgene poisoning she found to occur in dye works, 
which sometimes has been fatal. Also sulphureted hydrogen 
can cause serious acute and even fatal poisoning. 

As these poisons are all volatile, they enter the system 
through the respiratory tract, either as dust or fumes, but 
personal carelessness is probably a large factor, many times, in 
this poisoning. The greatest cleanliness is necessary, and 
changing the underclothing frequently, shower baths, etc., all 
tend to prevent such poisoning. Accidental poisoning from 
the sudden unexpected discharge of the fumes of these sub- 
stances will probably frequently occur. 

These poisonings are so insidious that it is suggested that 
individuals working in these plants be frequently visited by a 
physician, to note changes in the face color. If the individual 
looks gray, he should be quickly removed from his work to the 
outside air. 

TRINITROTOLUENE POISONING 

This substance, popularly known as T.N.T., is a high 
explosive which is produced by nitrating toluene, and is a 
benzene compound. When it is raised to a certain heat and 
then subjected to concussion it explodes; with heat alone it 
burns. 

Although precautions are taken against poisoning from this 
substance, such poisoning does occur, and the fumes are toxic. 
It is a serious irritant to the skin, and the hands and arms must 



742 THE PRINCIPLES OF THERAPEUTICS 

be protected, else severe inflammation occurs. Inhalations of 
this substance cause destruction of blood corpuscles, and when 
a worker in these factories shows a loss of hemoglobin and is 
becoming anemic, he should be prohibited from continuing work 
in the T.N.T. atmosphere. Another indication that an 
individual should no longer work in the T.N.T. factories is 
when bile pigments appear in the urine. Fumes from trinitro- 
toluene will cause the skin and hair to become yellow. 

Absorption of this substance may take place not only 
by inhalation, but also through the skin, and besides the 
serious poisoning evidenced by red blood corpuscle destruc- 
tion and jaundice, gastrointestinal disturbances of all kinds 
may develop. While at first the liver is enlarged, prolonged 
poisoning causes atrophy of the liver and degeneration of the 
kidneys. 

Voegtlin, Hooper and Johnson 1 suggest as a prophylactic 
against absorption through the skin a varnish made of shellac, 
castor oil and alcohol, to be applied to the hands and forearms, 
and then for the worker to use cotton gloves impregnated with 
a modification of this same varnish. They found the poison 
could be removed from the skin with sodium hydrosulphite 
solutions. 

The treatment, when poisoning occurs, is absolute rest, 
fresh air, and a bland, simple diet, with alkaline or mucilaginous 
drinks to soothe the mucous membrane of the gastrointestinal 
tract. Plenty of water and large doses of alkali, as sodium 
citrate or sodium bicarbonate, should be given. If jaundice 
is present the treatment would be the same as for catarrhal 
jaundice. The bowels should be kept open with gently acting 
laxatives. If it is inadvisable to allow meat, small doses of 
iron should be daily given. 

1 Public Health Reports XXXIV, iqiq. 



PART XI 
TREATMENT OF EMERGENCIES 

SUDDEN DEATH 

When a physician is called to a case of sudden death, or 
if a patient dies before he has been under his care for twenty- 
four hours, the death must be reported to the authorities, in 
most communities to the medical examiner. If the physician 
finds the patient dead on his arrival, he should remain with the 
body until the medical examiner has arrived, or at least until a 
policeman has taken charge of the body. In the meantime, he 
should allow no one to touch the body, and the physician 
himself should not disturb the individual except to positively 
ascertain that he is dead. If he finds the patient is alive, 
the physician has full charge of the case, and can do whatever 
he decides is necessary; although if he thinks that death 
is imminent, or that the circumstances of the injury or illness 
are suspicious, he should send for the authorities, the police 
or the medical examiner. 

Signs of death are: the absence of heart-beat, with the 
stethoscope over the heart; absence of befogging of a cold 
mirror held close to the nostrils; absence of swelling and dark 
hyperemia of a finger when a string is tied fairly tight around 
it; absence of dilatation of the pupil within a few minutes if a 
i per cent, solution of atropine is dropped into an eye. 

COMA 

If a patient is found in coma, this may be due to: injury; 
alcohol; apoplexy; epilepsy; uremia; diabetes; sunstroke; 
illuminating gas; carbon monoxide; or to poisoning from 
opium (in some form), chloral, or phenol. A quick survey will 
generally show whether or not there is an injury. The odor 
of alcohol is not necessarily evidence of alcoholic coma. An 
epileptic seizure followed by coma can generally be certified to 

743 



744 THE PRINCIPLES OF THERAPEUTICS 

by the bystanders; or some one may know that the subject is 
an epileptic; or froth at the mouth or a bitten tongue may give 
the clue. In an apoplectic attack there may also be frothing at 
the mouth, and there is generally stertorous breathing. In 
this condition the face will generally be found drawn to one side, 
and one arm and leg may not act as the other arm and leg, 
even though the patient is comatose. Uremic coma may not 
be preceded by a convulsion. It is rare, however for uremic 
coma to occur without sufficient premonitory symptoms for the 
individual to be under medical supervision. Diabetic coma 
may suddenly occur, and must always be considered as a 
possibility. Coma from sunstroke occurs only in heated 
periods when the individual has been exposed to the sun. The 
surroundings and the odor will diagnose the cause of coma from 
illuminating gas. The possibility of the coma being caused by 
carbonic oxide gas must be borne in mind, especially when the 
individual is at or near a furnace or in a garage, or is found 
in a cellar. 

In drug comas there are always some indications that poison 
has been taken. Chloral may have been administered surrepti- 
tiously in the form of " knockout drops." Coma comes on 
slowly after most poisoning with opium preparations. Phenol 
coma is more or less rapid, the lips are generally stained and 
burned, and the odor is characteristic. 

Sudden faintness in the beginning of acute disease may occur 
in cerebrospinal meningitis, and in some forms of influenza, and 
sudden paralytic symptoms may occur in botulinus poisoning 
and in wood alcohol poisoning. 

The pupils are contracted in all forms of opium poisoning; 
they may be contracted in uremia and in head injuries. They 
are generally dilated in alcohol and chloral poisoning, and in 
diabetes; one pupil may be dilated and the other contracted in 
apoplexy and in a head injury. The intensity of the coma will 
decide whether or not the pupils react alike. 

In most cases of coma it is advisable to .catheterize and 
quickly test the urine, as an aid to diagnosis. The treatment 
for these various conditions depends on the diagnosis of the 
cause. 



ILLUMINATING GAS POISONING 745 

ILLUMINATING GAS POISONING 
Carbon Monoxide Poisoning 

Illuminating gas, generally by accident but often by suicidal 
intent, is one of the most frequent causes of poisoning. 

Individuals found comatose from inhaling illuminating gas 
generally have an increased temperature (although in some 
instances the temperature is subnormal, especially in convales- 
cence), the pulse is generally rapid, and there is often a leuco- 
cytosis. If the coma is not profound, twitchings of the muscles 
and sometimes convulsions occur, and in some instances there 
is muscle rigidity. Prolonged coma is always serious and gen- 
erally shows that the outcome will be fatal. Rarely, gangrene 
of the hands and feet may follow carbon monoxide poisoning. 

Yandell Henderson, 1 who has made so many investigations 
of various kinds of asphyxias, finds that artificial respiration 
properly done with the individual prone (S chafer method) will 
accomplish more for resuscitation from drowning, electric 
shock, and asphyxia than is possible by means of any apparatus. 
But whether apparatus is used or manual artificial respiration 
is done, it is most important to remember that every minute's 
delay makes recovery more doubtful (ten minutes of complete 
asphyxia is probably fatal), hence if breathing has stopped 
artificial respiration should be begun immediately. 

In a later article 2 on carbon monoxide poisoning, Henderson 
states that carbon monoxide is responsible for more deaths than 
all other gases put together, and that this gas is the chief poison 
in suffocation from the smoke of burning buildings, from the 
fumes of furnaces and explosions, in the "after damp" of explo- 
sions of methane and coal dust in mines, and from mine fires 
either of timber or coal, and of course it is the important factor 
in poisoning from illuminating gas. Illuminating gas is com- 
posed in varying amounts (depending chiefly on the price of 
petroleum) of " water gas/' "coal gas," and the vapor from 
superheated or "cracked" petroleum. So-called "water gas" 
contains about 30 per cent, of carbon monoxide. It is compara- 

1 Journal A. M. A., July i, 1916, p. 1. 

2 Journal A. M. A., Aug. 19, 1916, p. 580. 



746 THE PRINCIPLES OF THERAPEUTICS 

lively cheap to manufacture, and is produced by blowing live 
steam over hot coal. The gas formed by the destructive dry 
distillation of coal, technically called "coal gas," contains only 
about 6 or 8 per cent, of carbon monoxide. It is therefore far 
less poisonous than "water gas." At the present time water gas 
is the chief ingredient of the illuminating gas of American cities. 

Henderson states that the poisonous activity of carbon mon- 
oxide is due to its avidity for hemoglobin with which it forms a 
combination similar to the combination of hemoglobin with 
oxygen,, but with an [attraction approximately 250 times as 
strong. The poisonous effects are largely due to prevention of 
the oxygen- carrying power of the blood. He also says that it is 
a mistake to believe that this carbon monoxide combination 
with hemoglobin is permanent, and that as soon as an adequate 
amount of pure air enters the lungs, the hemoglobin combina- 
tion with carbon monoxide begins to break up, and the higher 
the percentage of oxygen in the air inhaled, the sooner the car- 
bon monoxide is displaced and the sooner the oxygen-carrying 
capacity of the hemoglobin is restored. He believes that for 
half an hour it is beneficial to administer pure oxygen, or air 
enriched with oxygen, to the individual, and that practically 
all the carbon monoxide is eliminated and the hemoglobin fully 
restored in three or four hours. Recent investigations of Hen- 
derson and Haggard 1 indicate that inhalation of oxygen plus 
about 8 per cent, of carbon dioxide greatly accelerates recovery. 
The carbon dioxide augments breathing and the oxygen thus 
drawn in increases the rapidity of the elimination of the carbon 
monoxide. 

Although a patient may die unconscious even though he lives 
a day or two, it is not the condition of the blood that causes his 
death, nor is the prolonged coma due directly to the carbon 
monoxide, but to the oxygen deficiency which it causes in the 
blood, hence bleeding and transfusion of blood or of saline 
solutions are not indicated, and certainly there is no indication 
for such treatment after the first two or three hours. The 
patient will recover as soon as he receives plenty of fresh air if 
the asphyxia has not been too intense or too prolonged, although 

1 Journ. Pharmacol, and Exp. Thera., Aug., 1920, p. 11. 



ILLUMINATING GAS POISONING 747 

there may be muscular weakness and heart weakness for a long 
period. There also may be loss of vision and loss of speech for a 
time. Blood has been found in the spinal fluid. 

Henderson states that a man may have one-third of his red 
corpuscles saturated with carbon monoxide before he senses the 
intoxication, although he may do peculiar things during this 
period, on account of the disturbance of the brain caused by 
such poisoning. Exertion in this condition with the deficient 
amount of hemoglobin which is able to oxygenate, may cause 
him to collapse. Roughly, he states, a man will die who has 
breathed 0.2 per cent, of carbon monoxide mixed with air for 
four or five hours, or 0.4 per cent, inhaled for one hour. 
With from 2 to 5 per cent, of carbon monoxide, as after an ex- 
plosion of coal dust, nearly all of the hemoglobin is combined by 
the first few breaths drawn, and death follows almost as quickly 
as in drowning. This is the case also when illuminating gas 
only slightly diluted with air is inhaled. 

He comes to the conclusion that the proper treatment of 
carbon monoxide poisoning is to administer artificial respiration, 
if the patient's breathing has stopped. Thereafter inhalations 
of oxygen containing carbon dioxide (about 8 per cent.) to 
augment the breathing is the proper treatment. Keep the body 
warm, if the temperature is low; supply plenty of water to the 
system, perhaps by the Murphy drip. The Murphy drip 
solution may well contain sodium bicarbonate. Such alkaline 
treatment should not be too long continued. 

Defective ventilation, not only in mines, but in boiler rooms 
should be prevented. When there has been an explosion and in- 
vestigations must be made, and when firemen must go into 
smoky atmospheres, oxygen helmets should be used. The gas 
masks used by soldiers in war are quite ineffective and danger- 
ous against carbon monoxide. 

Chronic debility due to insidious poisoning from small 
leaks of illuminating gas in factories, offices and tenements is 
frequent. This kind of poisoning causes headache, indigestion, 
loss of appetite, lassitude and general debility. The over-use of 
gas stoves in ill- ventilated rooms, with leaky pipes or hose, and 
coal stoves that leak gas, and leaks around the gas meter in a 



74-8 THE PRINCIPLES OF THERAPEUTICS 

cellar, the gas permeating the whole building, are of constant 
and frequent occurrence, and the debility caused in individuals 
subjected to these fumes is not sufficiently recognized. In 
other words, chronic carbon monoxide poisoning is serious and 
should be prevented. 

WAR GAS POISONING 

The most important of these gases was mustard gas on 
account of the greater number of individuals poisoned by it. 
Chlorine was perhaps one of the most toxic of the gases, while 
phosgene and chlorpicrin were also very poisonous gases. 

Marshall 1 discusses mustard gas poisoning and states that 
it should not be considered as a gas at all, but as a boiling hot 
oily liquid which vaporizes slowly in the air. Therefore, be- 
sides the irritations of the respiratory tract, the eyes and skin 
are more or less affected. There is also a difference in the 
susceptibility of different individuals to the same amount of 
mustard vapor, and negroes are more resistant than white men. 
Those whose skins are hypersensitive suffer severe burns, while 
many others with less sensitive skins are not burned at all. 

Berghoff 2 states that the most pronounced early symptom of 
mustard gas poisoning is bleeding from the nose, associated 
with cough, dyspnea, sneezing, and other symptoms of irritation 
of the air passages. 

Berghoff describes the action of chlorine poisoning, which 
represented more than 30 per cent, of 2,000 cases studied by him. 
Poisoning from this gas caused many symptoms and required 
the patient to remain long in the hospital. He quotes Hill, of 
the English Medical Corps, as stating that the early symptoms 
of chlorine poisoning are subnormal temperature, slow pulse, 
cyanosed face, dyspnea, and frothy expectoration. This 
asphyxial stage lasts about thirty-six hours, to be followed by 
bronchitis and expectoration of greenish mucopurulent sputum 
with increased temperature and rapid pulse. During this 
period the expansion of the chest is diminished. Hill thinks 
that the lungs should recover from this condition as readily as 
from bronchopneumonia. 

1 Journal A. M. A., Aug. 30, 1919, p. 684. 
2 Archiv. Int. Med., Dec, 1919, p. 676. 



WAR GAS POISONING 749 

Phosgene gas poisoning causes cough, bloody sputum, sneez- 
ing, and great weakness, the debility lasting sometimes for 
weeks. 

Berghoff did not find that gas victims were predisposed to 
tuberculosis, and they did not show evidence of lung destruction, 
but those who suffered from emphysema, about 22 per cent, of 
2,000 cases, had a very protracted convalescence. 

Underhill 1 who did a great amount of experimental work in 
devising preventive measures for these gas poisonings, states 
that chlorine, phosgene, and chlorpicrin are alike as far as their 
action on the respiratory tract is concerned, all producing edema 
and congestion, chlorine acting very rapidly, while phosgene is 
slower in its action, and the rapidity of chlorpicrin action is 
between the other two. He states that "gassing has a definite 
influence on the respiration, heart-beat, temperature, concentra- 
tion of the blood, the water content of the lungs and other 
tissues, the chloride content of the tissues (with resulting 
changes in chloride excretion by way of the kidneys) , the num- 
ber of red and white cells of the blood and the respiratory 
function of the blood, leading to dyspnea and partial asphyxia. 
Acidosis is present at times." Phosgene poisoning causes at 
first a dilution of the blood rather than concentration, while 
chlorine gas rarely, if ever, causes dilution, probably always 
concentration. 

Underhill states that while it has been thought that edema 
of the lungs was generally the cause of death, death is really 
due to concentration of the blood which causes a failing circula- 
tion, insufficient oxygenation, fall of temperature and collapse. 
Therefore he urges that the whole aim of treatment should be to 
prevent blood concentration. If the poison causes at first 
dilution of the blood, venesection is indicated, and later when 
the period of concentration develops, physiologic saline should 
be introduced into the blood vessels. He suggests venesection 
when practicable immediately after gassing to the extent of 
about 0.5 per cent, of the body weight. The hemoglobin index 
and the temperature should then be watched at half hour in- 
tervals, and as long as the temperature remains normal and 

x Archiv. Int. Med., Dec, 1919. 



75° TH E PRINCIPLES OF THERAPEUTICS 

blood concentration does not diminish, further treatment, he 
believes, is not necessary. As soon, however, as "the tempera- 
ture rises rapidly and a fall in blood concentration occurs (the 
two changes take place simultaneously) a second venesection of 
0.5 per cent, of the body weight is indicated," and this venesec- 
tion may be again repeated, if necessary, to the extent of 1.5 
per cent, of the body weight. 

If, in spite of this intensive treatment in the first stage, the 
blood becomes much concentrated and there is considerable fall 
in temperature, the condition is serious and must be actively 
treated by infusions of saline solutions. Plenty of water should 
also be given by the mouth. Oxygen inhalations are often of 
benefit, but are not curative. In chlorine poisoning there is 
likely to be acidosis; therefore sodium bicarbonate in large 
doses, by the mouth, should be given. 

Winternitz 1 describes the pathology of gassing, and states 
that the danger in the first stage of poisoning is from the irrita- 
tive and escharotic action of the gas on the upper air passages, 
and that the acute congestion and edema is a cause of the early 
deaths. A later cause of death is the pneumonic process which 
developes. If death does not occur from the pneumonic pro- 
cess, serious necrosis of some part may be caused by some gases, 
and that may be a later cause of death. In some cases the 
chronic pathology is that of tubular or saccular bronchiectasis, 
or bronchiolectasis. Some of the lasting disturbances from 
gassing are due to contraction of scarred tissue, and before such 
scars cause contraction, Winternitz suggests graded respiratory 
exercises. 

Barbour 2 finds by experimentation that morphine in not 
large doses may be safely given to stop pain in chlorine gassed 
individuals ; that epinephrine has no favorable influence ; and 
that subcutaneous injections of calcium lactate does not prevent 
edema of the lungs. 

CAISSON DISEASE 

Men working under water in diving suits and those working 
in caissons are surrounded by air at high pressure. If this 

1 Archiv. Int. Med., Dec, 1919. 

2 Journ. Pharm. and Exp. Thera., Sept. and Oct., 1919. 






DROWNING 75I 

pressure is not kept just right, and the exchange of the air in 
the diving suit or caisson is not just right, the ear drums are 
disturbed and oppression, lassitude and faintness will occur, 
and the body is likely to become overheated. If the carbon 
dioxide becomes excessive of course asphyxia occurs. 

Much of the danger to workmen under these conditions 
occurs from too rapid decompression ; they must gradually come 
to the pressure of the outside atmosphere. If decompression 
from high pressure is too rapid, men suffer from severe pains, 
especially in the arms and legs. This has been termed "the 
bends." Rapid change of atmospheric pressure may cause 
nervous disturbances and, especially, injury to the spinal cord, 
perhaps followed by paralysis and coma. The cause of caisson 
disturbance has been shown to be due to nitrogen gas in the 
blood-vessels and tissues. 

An insufficient amount of oxygen in a diving suit or in a 
caisson means suffocation, and either oxygen must be rapidly 
introduced in sufficient amount, or the suffocated patient must 
be treated for carbon dioxide poisoning, i.e., by oxygen and air, 
and artificial respiration. 

To prevent the symptoms of decompression, the individual 
must be slowly decompressed, and if symptoms appear he must 
be again subjected to an increased compression for a short 
time. If serious symptoms develop, inhalations of oxygen are 
of value, oxygen aiding in the exchange and elimination of the 
extra nitrogen in the body. 

DROWNING 

A person who has been submerged in water more than five 
minutes can rarely be revived. However, even if the heart 
has apparently ceased to beat, artificial respiration may cause it 
to begin again to pulsate. The immediate treatment should be: 

1. To get the water out of the lungs and stomach. 

2. To begin artificial respiration. 

3. To stimulate with atropine, caffeine and strychnine 
injections. 

4. To surround the patient with dry heat, and keep him 
quiet and at rest. 



752 THE PRINCIPLES OF THERAPEUTICS 

i. To accomplish the first object, the body may be suspended 
for a few minutes by the heels, or it may be laid on the abdomen 
over a barrel or some other large, rounded object. The head 
should be below the chest level. The body should then be 
turned on the back (if the water has ceased to run out of the 
lungs and stomach), the nose cleaned, and the mucus removed 
from the mouth with the fingers and a handkerchief. 

2. Artificial respiration should be immediately begun, and 
probably there is no better method for causing artificial respir- 
ation than the S chafer. The patient lies prone (chest and 
abdomen downward, with the head turned to one side), and 
the operator sits at his side and makes firm pressure inwards 
and upwards on the body, the hands being broadly placed 
laterally against the region of the lower floating ribs. This 
pressure is exerted for three seconds, and then the body is 
released and the diaphragm drops, the capacity of the chest is 
increased, and air is sucked into the lungs. This alternate 
pressure and relaxation should be repeated from twelve to 
fourteen times a minute. If the patient begins to breathe, he 
may be turned on his back and his efforts aided by the Sylvester 
method of artificial respiration. The tongue must not be 
allowed to fall back over the glottis, and may either be held by 
tongue forceps, or a thread may be passed through it to hold it 
forward. While the operator is doing the artificial respiration, 
others should loosen the clothing, and gently, but firmly, give 
friction to the arms and legs, and perhaps hold the legs up, so 
that the blood of the body will gravitate toward the brain. 
If the patient starts to respire, rhythmical pulling forward of 
the tongue about fifteen times a minute seems to be a respir- 
atory stimulant. The operator must be careful to coincide in 
his efforts at artificial respiration with the beginning efforts of 
the patient to respire, and not antagonize them, so that the 
rhythm will be synchronous. If the heart continues to beat 
and the patient respires at all, or artificial respiration seems 
to be keeping the patient alive, it should be continued until the 
patient either breathes freely, or the heart has ceased to beat 
for ten or more minutes. 

3. While artificial respiration is being done, or if it has 



burns 753 

succeeded or is not necessary, the respiratory and vasomotor 
centers must be stimulated, and hypodermatic injections of 
atropine ^{qo grain and strychnine 3i*o grain should be given 
immediately. If the patient can swallow, black coffee should 
be administered, or coffee may be administered by the rectum; 
or sodio-benzoate of caffeine may be given hypodermatically in 
3-grain doses. Camphor may also be administered hypo- 
dermatically. 

4. The body must be kept warm by friction, hot water bags, 
and warm blankets. Respiration and circulation having been 
established, the immediate subsequent treatment is absolute 
rest, the administration of some warm gruel or more coffee, and 
the continuation of dry heat. The future treatment may be 
that for a cardiac strain, if the patient labored severely before 
he succumbed; or for an insufflation pneumonia, if that develops. 

BURNS 

Burns are divided into three classes or degrees, depending 
on the depth and severity of the injury. 

The primary considerations in the treatment of burns are: 
(1) to allay pain; (2) to protect the skin and burned tissues; 
(3) to prevent infection; and (4) to promote healing and repair. 

While simple burns cause only slight uncomfortableness or 
disability, burns of considerable areas of the body may cause 
death sooner or later, or may cause such internal disturbances 
as duodenal inflammation and nephritis. When too hot air is 
inhaled swelling of the mucous membrane of the throat and 
larynx may be so great as to cause death. 

In burns of the first degree where there is but slight blister- 
ing, the first treatment is to apply, freely, a solution of bicar- 
bonate of sodium in water; or the part may be immersed in it, 
the water being at the temperature of the body, i.e., lukewarm. 
A compress wet with a Ji to 1 per cent, solution of aluminum 
subacetate will often relieve the local pain. Soon, in ten or fifteen 
minutes, the part should be gently dried and a dry powder 
applied, such as starch, talcum, or bismuth subcarbonate. 

In burns of the second degree, where there are blisters, the 
same primary treatment is advisable. Later a sterilized needle 

48 



754 THE PRINCIPLES OF THERAPEUTICS 

should be inserted at the outer and most pendent angles of the 
blisters and, by allowing the serum to gently exude, there will 
be relief from the painful distention. Great care should be 
taken not to destroy or break this epidermal layer of skin, as 
it makes the very best aseptic protection for the underlying 
inflamed skin. Sometimes the moist dressings of weak alumi- 
num subacetate are retained in place by oil silk, but it is inad- 
visable to allow a poultice effect to occur. It is much better 
to repeatedly moisten the gauze, to prevent it from drying, 
rather than to allow sweating to take place. The old carron 
oil treatment is sedative, but may allow infection. After the 
first twenty-four hours there is no moist dressing better than a 
saturated solution of boric acid. 

The burned surface should be dressed, generally, twice a day, 
and the shriveled, loosened or broken derm should be carefully 
removed with forceps, or a partially loosened piece may be cut 
away with scissors. Nothing promotes healing much more 
rapidly than exposure to the air for a short time, taking care that 
the part is protected by thin gauze, or other method, from 
infection by flies or dust. 

If there is considerable destruction of epidermis in any par- 
ticular area, silver foil treatment is satisfactory, it being re- 
applied daily where it is needed, aiming toward drying the part. 
If any exuberant granulations occur which prevent the skin from 
growing in, they should be just touched with a swab wet with 
a 25 per cent, nitrate of silver solution; but the proper application 
of silver foil will prevent the development of much exuberant 
granulation tissue. 

Burns of any severity cause most intense and severe pain 
and, consequently, shock. Hence one of the primary treatments 
is injections of morphine with atropine, if the pain is severe. 
If shock has occurred, stimulation with strychnine, with supra- 
renal, and with caffeine may be necessary. 

In the beginning of the treatment air causes the exposed 
skin to suffer pain, consequently exposure to air is not advis- 
able in the early stages of these burns. Many other solutions 
have been advised other than the sodium bicarbonate, the 
aluminum subacetate, and the boric acid, but they are not more 



burns 755 

satisfactory, and several of them (permanganate of potassium 
and picric acid) stain everything with which they come in 
contact. 

If healing is slow, continued bathing of the part with physio- 
logic saline solution, or, if there is danger of infection or there 
has been much destruction of tissue, one of the Dakin solutions 
is advisable, and, if there is any sloughing of tissue, the part 
should be carefully washed with the Carrel-Dakin solution. 
With burns of the second degree it is sometimes necessary to do 
skin grafting. 

During the prolonged and tedious healing of large mulitple 
burns, the nutrition must be carefully kept up, sleeplessness 
prevented, and all the functions of the body should be watched, 
and kept as normal as possible. 

Burns of the third degree, where there is actual destruction 
of tissue, belong to the department of surgery, and the manage- 
ment of the case can only be determined by the individual 
conditions present. Suffice it to say, that pain must be stopped, 
that shock must be prevented, if possible. Some of the 
toxemias, and some of the shock and perhaps anaphylactic 
reactions caused, are due to destruction of tissues, and the ab- 
sorption of protein poisons from these tissues. The suprarenal 
glands seem to be disturbed, hence one cause of the low 
circulatory tone. The heart may become disturbed, and the 
liver and kidneys insufficient. Severe burns are frequently 
more or less rapidly fatal. 

The patient surviving the first twenty-four hours, the danger 
of infection is great, and the danger of resorption of toxins from 
sloughing tissues is great. The Carrel-Dakin solution used 
intermittently or constantly is an important aid in preventing 
infection and promoting reconstruction of tissues, and prevent- 
ing deformities from contractions. The ultra-violet ray has 
been used with success for the same purpose. 

The paraffin treatment of severe burns has lately been 
strongly advocated. Liquid paraffin is sprayed or painted over 
the wounds. The advantage is that it protects the burned area 
and seems to allow less contraction of the new tissue and there- 
fore a better, more flexible scar. Before applying, the part 



756 THE PRINCIPLES OF THERAPEUTICS 

must be thoroughly cleansed and then dried with hot air, by 
fanning or with an electric drier, and then the liquid paraffin is 
applied hot, sometimes in layers with gauze between the layers. 
The whole part is then gently bandaged with a layer of cotton- 
between the paraffin and the bandage. In subsequent dressings 
the whole wax layer may be easily and gently removed. If infec- 
tion occurs, the Dakin solution should be used daily before the 
new dressing is applied; or it may be inadvisable to use the 
paraffin dressing. When the paraffin dressing is used, ordi- 
narily, it should not be changed for twenty-four hours. With 
some of the terrible burns sustained by the soldiers in the late 
war, life seems to have been saved, and discomforts were less 
under this paraffin treatment. 

Sollmann has suggested the use of liquid petroleum as the 
first layer over a burn and the paraffin coating to follow. 
The first layer of petroleum prevents the pain from the subse- 
quent paraffin coatings, while the primary paraffin coating is 
painful. It should be recognized that if the burns are large 
and multiple, the paraffin treatment is tedious of application. 
Sollmann also suggests an ointment of three parts of surgical 
paraffin and seven parts of liquid petroleum as a satisfactory 
dressing for burns. Surgical paraffin, ready for use for burns, 
can now be obtained. 

The removal of hopelessly necrosed and burned tissue, the 
prevention and treatment of contractions and scar tissues, and 
the renewal of motility and function belong to several depart- 
ments of surgery, and the repair possible is sometimes far be- 
yond expectation. 

Burns of the Eye. . — If the burn is from acid, the immediate use 
of cold water and of weak alkaline solutions, as bicarbonate of 
sodium, is essential. If the burn is from an alkali or from 
lime, which occurs not infrequently, immediate applications 
of cold water and weak vinegar solutions are essential. 
The next treatment should be a few drops of a 4 per cent, 
solution of cocaine, and then, the eye being gently bandaged 
with gauze soaked in 3 per cent, boric acid solution, the patient 
should be transported to a hospital or to an oculist for expert 
treatment. 



ACUTE POISONING BY DRUGS 757 

TREATMENT OF ACUTE POISONING BY DRUGS 

The chemical reactions, the physiologic disturbances, and 
the toxic symptoms caused by the poisonous drugs are not here 
outlined, as it is assumed that such knowledge has already been 
acquired. It is necessary only to recall that the poisonous drugs 
are primarily irritants, excitants, or sedatives. The irritants 
may cause local symptoms only or may cause systemic symptoms 
subsequent to the local irritation. The excitants may or may 
not cause local irritation, but they more or less seriously stimu- 
late the central nervous system. The sedatives are generally 
not local irritants, and they depress the circulation and central 
nervous system. 

The symptoms of acute poisoning by drugs, will, of course, 
vary with the character and activities of the drugs. The 
severity of the irritant action and the rapidity of the absorption, 
and hence the rapidity of the development of the symptoms, 
depend upon whether the stomach is full or empty when the 
poison is swallowed. The irritants cause pain, vomiting, 
diarrhea, and more or less (depending on the poison) erosion, 
perforation and subsequent cicatrices. The most frequent 
irritant poisons are strong acids, strong alkalies, arsenic (rough 
on rats), corrosive sublimate, lead acetate, oxalic acid, phos- 
phorus (match heads, ratbane), and potassium chlorate. 
Arsenic, corrosive sublimate, lead, and phosphorus cause 
serious symptoms after absorption, more especially liver and 
kidney lesions. 

The excitant poisons stimulate the heart and irritate the 
brain and spinal cord. Depression may follow such excitement 
or irritation. The drugs that most frequently cause such 
poisoning are those containing atropine, scopolamine, and 
cocaine. Caffeine and volatile oils may cause such poisoning 
in mild degree. 

The sedative poisons may act only on the circulation (as 
digitalis and aconite), or they may depress the cerebral and 
spinal nerve centers and secondarily depress the circulation. 
The drugs most frequently causing this kind of poisoning are 
bromides, chloral, cyanides (prussic acid), and the opium group. 



75$ THE PRINCIPLES OF THERAPEUTICS 

Aspidium, santonin, thymol and wormseed oil may cause such 
poisoning. All of the coal-tar drugs (acetanilid, antipyrine, 
aspirin, phenacetin, etc.), the phenols (carbolic acid, etc.), and 
all synthetic hypnotics (luminal, sulphonal, trional, veronal, 
etc.) , are depressant poisons, acting especially on the heart. 
The aims of the treatment of acute poisoning by drugs are: 

(i) To prevent absorption of the poison. 

(2) To neutralize the poison. 

(3) To promote the elimination of the poison. 

(4) To counteract the effects of the poison. 

(5) To restore the convalescent patient to health. 

1. To meet the first indication the stomach must be rapidly 
emptied, either by vomiting or by washing it out by means of 
the stomach tube. Most irritant poisons, unless the stomach 
is full, have already caused vomiting before the patient is seen. 
If vomiting is sufficient, warm water drinks should be given, 
containing an alkali as bicarbonate of sodium if the irritant was 
an acid, or containing vinegar if the irritant was an alkali, or 
containing the special antidote for the poison, if the poison is 
known. If the poison taken is corrosive, the stomach tube 
should not be passed. If vomiting has not taken place, an 
emetic must be given, as mustard water, ipecac in any form ob- 
tainable, 0.50 Gm. (j}i grains) of copper sulphate in solution, 
or 2 Gm. (30 grains) of zinc sulphate in solution. If the poison 
is not irritant and vomiting does not quickly occur, a hypoder- 
matic injection of the hydrochloride of apomorphine (Ho grain) 
should be given, unless there is great prostration. If there is 
prostration the stomach tube must be used. 

When it is decided that the stomach is empty, morphine 
should be administered hypodermatically, if the drug was an 
irritant and severe pain is suffered. Also, if the drug was an 
irritant, albumin water, milk, or mucilaginous infusions (as 
starch solutions; flaxseed or slippery elm infusions), should be 
freely given. If the poison was an alkaloid, tannic acid in 
water should be administered. If the poison was arsenic, the 
official antidote ("iron hydroxide with magnesium oxide") 
should be given in 3 or 4 ounce doses. If the poison was lead 



ACUTE POISONING BY DRUGS 759 

acetate, half a teaspoonful of dilute hydrochloric acid, in water, 
may be given, well diluted, and repeated several times, and 
later sodium sulphate, 30 Gm, should be given. If the poison 
was corrosive sublimate, raw eggs should be quickly beaten up 
and administered. If the poison was phosphorus, the best 
emetic is copper sulphate, and after vomiting the stomach 
should be washed out with 1-1000 permanganate of potasium 
solution. Later magnesium or sodium sulphate should be 
administered. 

2. To meet this indication drugs should be administered 
that combat the effects of the poison after absorption. Many 
of the irritant poisons cause no systemic effects, as they are 
not absorbed; the exceptions are: arsenic, lead, mercury and 
phosphorus. All of these may cause, besides the local in- 
flammation, nephritis and some disturbance of the liver; 
phosphorus is especially irritant to the liver. There is no drug 
that will act immediately to counteract these poisons in the 
system, consequently, the treatment of the pathology caused by 
these poisons becomes the treatment of the subacute condition 
and of the convalescence. 

Poisons that cause nervous excitement may be combated by 
the opposite acting drugs, such as bromides and chloral, and, if 
there are convulsions, chloroform inhalations may be given. 
Morphine may be advisable, but many times unless the dose is 
dangerously large it may increase the excitement in these con- 
ditions of cerebral irritation. Ergot given intramuscularly is 
often one of the best sedatives for this kind of cerebral irritation. 
If circulatory weakness follows the nervous excitement, cardiac 
stimulants may be needed. 

If the poison is a nervous sedative, then neutralizing drugs 
are indicated, as atropine, caffeine, strychnine, camphor, 
and, in circulatory depression, suprarenal and pituitary, all 
given hypodermatically. 

3. To meet the third indication, besides evacuation of the 
stomach, quick acting cathartics should be given, and saline 
cathartics are generally the most useful. Unless there is severe 
pain, as in irritant poisoning, necessitating the early adminis- 
tration of morphine, catharsis should be caused before the seda- 



760 THE PRINCIPLES OF THERAPEUTICS 

tive is given. If it is considered that there has been much 
erosion from an irritant drug, and the irritant has been long 
enough in the stomach to have perhaps passed into the duode- 
num, castor oil is the best cathartic; later olive oil and mineral 
oil may be given for the soothing effect. If a drug is slowly 
eKminated, the patient should be given large amounts of water, 
both by stomach and by rectum, especially if the poison is arse- 
nic, mercury, or phosphorus. In corrosive sublimate poisoning 
this treatment should be continued sometimes for days; even 
the Murphy drip treatment may be advisable. 

When a coal-tar or synthetic drug has caused poisoning, 
sodium bicarbonate solutions should be given freely, as this 
alkali seems to neutralize the effect of these drugs, especially 
on the heart. 

4. The most frequent primary symptom of poisoning, unless 
it is of the sedative class, is pain, and pain, if severe, must be 
quickly stopped before it has caused shock and circulatory de- 
pression. Chilling of the body should not be allowed, and un- 
less the poison taken was a nervous excitant or irritant, the 
patient should be surrounded with hot water bags, as most seri- 
ous poisoning is followed by collapse, shock, and great loss of 
heat from the body. Any drug which will combat the physiolog- 
ic activity of the poison should be utilized. Cerebral excitants 
should be combated with depressants, cerebral depressants 
with cerebral excitants, and cardiac depressants with cardiac 
stimulants. In treating circulatory weakness or heart failure, 
warmth to the body and dry heat over the heart are valuable 
aids in causing improvement. The drugs to meet this kind of 
circulatory failure are those that act quickly, and most treat- 
ment must be given hypodermatically. Atropine, caffeine and 
strychnine are the drugs first to be considered, unless the patient 
is already in an excited condition and the poisoning has caused 
cerebral excitation. Sterile solutions of camphor, ergot, pitu- 
itary, and suprarenal extract may be used. Strophanthin may 
be given intravenously in a dose of JI300 of a grain. 

It is not advised that all of these drugs be used on the same 
patient at the same time, but a wise choice should be made; too 
much should not be done. Great reliance should be placed 






CORROSIVE SUBLIMATE POISONING 76 1 

upon intramuscular injections of an aseptic ergot, i mil (15 
minims) and repeated in half an hour, if needed. Also reliance 
should be placed on coffee, especially if this can be retained in 
the stomach; or coffee may be administered by rectum. Cam- 
phor hypodermatically can be several times repeated. It is a 
mistake to give too much strychnine, pituitary extract, or epine- 
phrine. In poisoning by some nervous depressants, especially 
morphine, it may be necessary for artificial respiration to be 
done for many hours. 

5. The treatment of the convalescence, which may be pro- 
tracted, naturally depends upon the character of the poison, the 
amount of damage that it has done,the length of time it takes 
that particular poison to be eliminated, and the seriousness of the 
pathology which the poison may have caused. The poisons 
that cause cerebral irritation, those that cause stupor, and those 
that cause severe cardiac depression (if the patient is to recover) 
are soon eliminated, and the patient is practically well. The 
poisons that corrode may have caused such ulceration as to pro- 
duce, later, large cicatrices or perforation, therefore the future 
is sometimes long in doubt. Those drugs that may produce 
serious lesions, especially of the liver and kidneys, and those that 
destroy blood-corpuscles, as potassium chlorate, cause a long, 
tedious and anxious convalescence. The prevention and treat- 
ment of nephritis in corrosive sublimate poisoning will be found 
outlined under that special heading. A single poisonous dose 
of lead acetate or of arsenic would rarely cause chronic poisoning 
as occurs when these drugs are taken in small amounts for a 
long time. 

The convalescent patient generally needs tonics, and 
especially iron, for some time. He may have circulatory 
weakness, and more or less severe gastrointestinal dis- 
turbances for many weeks. The treatment of these conditions 
need not be here outlined. 

CORROSIVE SUBLIMATE (MERCURIC CHLORIDE) POISONING 

Owing to accident and to suicidal intent, and to the avail- 
ability of corrosive sublimate tablets for antiseptic purposes, 
mercuric chloride poisoning has become very frequent. 



762 THE PRINCIPLES OF THERAPEUTICS 

The immediate symptoms of poisoning from corrosive 
sublimate are those of burning and irritation in the throat and 
esophagus, nausea, vomiting, and epigastric pain. The rapidity 
with which these symptoms develop depends upon whether or 
not the stomach is full. If the stomach is empty and the 
vomiting is more or less immediate, symptoms of intestinal 
irritation, as diarrhea, do not soon develop, but, if the poison 
remains longer in the stomach and with the food passes into 
the intestines, intestinal colic and diarrhea, with later symptoms 
of duodenal inflammation, occur. Blood is often vomited, and 
blood may later appear in the stools, and, if considerable 
amounts of the poison have been absorbed, nose-bleed may 
occur, and there may be hemorrhages from other parts of the 
body, especially from the uterus. 

There may be cerebral symptoms, as convulsions and coma, 
or the patient may die in collapse. Later symptoms are 
referable largely to the kidneys; first an albuminuria, later 
suppression, general nephritis, and uremic death. Other, later 
symptoms are those of ulcer of the stomach and intestines, duo- 
denitis, and sometimes jaundice. The patient may linger with 
these serious symptoms for several weeks before death occurs. 

Treatment. — If the patient has not already freely vomited, an 
emetic should be immediately given while other treatments are 
being prepared. It is well to have the vomitus examined for 
mercuric chloride, as sometimes the patient makes a mistake 
in what he has taken and is subjected to a long period of 
unnecessary treatment. 

The researches of Lambert and Patterson 1 and later modifica- 
tions suggested by Fantus 2 has developed the following 
suggestions for treatment: 

On first seeing the patient he should be given the whites of 
three eggs, and then the stomach should be washed out. Later 
he is given a pint of egg albumin water and the stomach again 
washed out. After this a tablet suggested by Fantus, composed 
of sodium phosphite 0.36 Gm. and sodium acetate 0.24 Gm. 
should be dissolved and administered at once. If sodium 

1 Archiv. Int. Med., Nov., 191 5. 

2 Journ. of Lab. and Clin. Med., 1916 and 1917. 






CORROSIVE SUBLIMATE POISONING 763 

phosphite cannot be obtained, a solution of sodium hypophos- 
phite 1 Gin,, hydrogen peroxide 5 mils and water 10 mils should 
be administered with water. Theoretically it has been esti- 
mated that if the amount of poison taken is known, ten times 
that amount of hypophosphite should be given, but if such an 
amount of hypophosphite is given, it should be immediately 
washed out with warm water by siphonage and then a smaller 
dose of the hypophosphite antidote given. 

As subsequent treatment it seems best to give a glass of 
albumin water every second hour for some little time, and if 
much irritation of the stomach has been caused by the poison 
(which can be estimated by the amount of vomiting and pain, 
and whether or not the stomach was empty when the poison 
was taken) demulcents should be given, perhaps best starch 
water, i Gm. of sodium acetate dissolved in water may be 
given every three hours for a day or two after the phosphite or 
hypophosphite mixture has been stopped. 

If the corrosive sublimate has had time to be absorbed in 
any amount, the next object of treatment is to protect the 
kidneys, and toward this end alkalies should be given, and 
plenty of water, and Lambert and Patterson suggest the drop 
method of rectal irrigation for this purpose, with a liquid 
carrying a solution of an alkali, about 4 Gm. (1 drachm) to 
500 mils (a pint). They suggest potassium acetate, but 
probably the milder sodium citrate would act as well, and 
sodium salts are better than potassium salts. Also the colon 
should be irrigated twice daily to of sure and remove all 
mercury that may have reached that region, and it is well 
to wash out the stomach twice daily for the first few days, unless 
the patient vomits repeatedly, to be sure to remove any mercury 
that is excreted into the stomach. 

As troublesome as the Murphy drip may be, Lambert and 
Patterson urge that it is necessary to repeat this treatment at 
short intervals until such time as two examinations of the urine on 
successive days have shown a negative test for mercury. They 
also urge that, if a very large amount of mercury was absorbed, 
or if the kidneys were previously damaged, the above treatment 
should be used intermittently for three weeks. 



764 THE PRINCIPLES OF THERAPEUTICS 

If acute nephritis actually develops, the treatment is of 
that lesion, and although Lambert and Patterson advise sweating 
and hot packs, this seems inadvisable. If the kidneys cannot 
act, it seems unwise to concentrate the poison in the blood by 
profuse sweatings. Also, if there is edema, it seems inadvisable 
to introduce large amounts of water into the system. Hot 
applications to the back are beneficial. 

As there is a tendency to acidosis in all conditions where 
there is vomiting and where food cannot be administered, espe- 
cially carbohydrates, alkalies are advisable, and the "imperial 
drink'' suggested by Weiss 1 which consists of potassium bitar- 
trate 4 Gm., sodium citrate 2 Gm., sugar 4 Gm., and a little 
lemon juice, in water up to 250 mils, makes a very pleasant 
method of administering the alkali. It is well to have the 
potassium bitartrate and the sodium citrate in powder form to 
dissolve in the lemonade just before it is to be drunk. This 
seems good treatment, for it not only offers a pleasant alkali 
but also sugar, and sugar and starches, as soon as starches can 
be retained, tend to prevent the acidosis that is likely to 
develop. Also to protect the kidneys, and especially if acidosis 
has developed, alkaline solutions may be injected into the 
colon. 

In spite of these strenuous treatments and of the apparent 
success it is doubtful, if a poisonous dose has actually been 
absorbed, whether life can be saved; however, whether or not 
a lethal amount has been absorbed can never be determined 
at the time of the active treatment. Even excessive doses 
taken into the stomach may, for some reason, not be absorbed, 
and may be rapidly eliminated by the emetic measures inaugu- 
rated. On the other hand, a small poisonous dose may be 
largely and rapidly absorbed. 

WOOD ALCOHOL (METHYL ALCOHOL) POISONING 

Methyl alcohol poisoning had occasionally occurred and been 
described, but lately poisoning from this substance has become 
very frequent on account of the prohibition laws. This deadly 
alcohol has been taken by accident; distributed by intent; and 

1 Journal A. M. A., June 2, 191 7. 






WOOD ALCOHOL POISONING 765 

used to adulterate all kinds of beverages. It has even been 
shown that producers and distributors have been perfectly 
cognizant of the fact that it was a deadly poison, and yet they 
have allowed innocent individuals, to suffer permanent injury 
or be killed by this alcohol. Hanging is too good for such 
miscreants. 

Methyl alcohol occurs in the distillate of wood, while ethyl 
alcohol, grain alcohol, is obtained from the fermentation of 
grains and fruits. Beverages made from methyl alcohol can 
generally not be distinguished from those made with ethyl 
alcohol, although large amounts of methyl alcohol will furnish 
a distinctive odor. Chemically the ingestion of methyl alcohol 
is shown by a large increase of formic acid in the urine. 

The primary symptoms of wood alcohol poisoning are dizzi- 
ness, perhaps nausea and vomiting, some disturbance of vision, 
and more or less befogging of the brain. Later in some cases, 
rapidly in other cases, blindness occurs with the pupils widely 
dilated. If the poisoning is fatal, the circulation becomes 
weakened, there may be delirium, then coma and death. 
Blindness is probably rarely followed by recovery of vision, 
although the patient may live after blindness has occurred. 
Whether the blindness and cerebral symptoms are due to the 
formation of formic acid has not been determined, but there is 
no known antidote. 

The only treatment of such poisoning is the rapid evacuation 
of the stomach, purging, and the administration of stimulants, 
as coffee and atropine. Perhaps it would be wise to do vene- 
section and then introduce a physiologic saline solution into 
the veins. 

So many times stupor and coma are due to acidosis, that it 
would seem wise to treat a case of methyl alcoholic stupor as 
though acidosis were the cause. Certainly it would do no 
harm, after the stomach had been emptied and an evacuating 
enema had been given, to introduce, both into the stomach and 
into the bowel, sodium bicarbonate and sodium citrate solutions. 

The toxic dose of wood alcohol may vary, at least it has not 
been determined definitely, but repeated small doses apparently 
will cause cumulative poisonous effects. In animals who have 



766 THE PRINCIPLES OF THERAPEUTICS 

been given small doses it has been found that fatty degeneration 
of the liver has occurred, but in acute poisoning in man no 
special pathologic conditions have been found, except slight hem- 
orrhages in the walls of the gastrointestinal mucous membrane. 

Small doses of methyl alcohol may cause blindness, and even 
after improvement from such blindness has occurred, later 
total blindness may develop from atrophy of the optic nerves. 

Not infrequently wood alcohol poisoning has occurred from 
drinking so-called denatured alcohol, which is officially 10 per 
cent, of wood alcohol added to ethyl alcohol. 

BOTULISM 

The name "botulism" was first applied to poisoning caused 
by sausage, therefore it is not a good name for the poisoning 
caused by infected canned foods. While the majority of this 
poisoning in this country occurs from home canning, some groups 
of poisonings have been caused by food supposed to have been 
properly sterilized at the canneries. 

The bacillus botulinus is killed by a temperature of 8o° C. 
(176 F.), but the spores of this bacillus may not be killed by 
careless sterilization. The bacillus botulinus seems to be widely 
distributed in nature, therefore vegetables and fruits may readily 
become contaminated with this germ. All spoiled foods are 
not infected with this bacillus, but any spoiled food may contain 
this deadly germ. The least change in color or appearance 
of the canned goods, or the least abnormal or unpleasant odor 
should cause the contents of the can to be destroyed, even if it 
is a fact that if the canned food is boiled the bacillus botulinus 
will be killed. 

Although it seems proved that properly sterilized and prop- 
erly canned goods cannot become infected with this bacillus, so 
many instances have occurred of deaths from this deadly poison 
that every can, wherever obtained, should be considered under 
suspicion until its contents are studied. Even a slight taste of 
the contents of an infected can has caused death. Some of the 
most unfortunate poisonings have occurred from canned as- 
paragus and from canned ripe olives. 

It should be emphasized that food contaminated with the 



BOTULISM 767 

bacillus botulinus may not be made sterile by ordinary methods 
of sterilization, and the public canneries must be more thorough 
in the application of heat to preserve their canned goods, and 
home canning should be most carefully done. 

The working rule of the kitchen of the household should be 
that any canned food of disagreeable smell or of unusual appear- 
ance should be destroyed; that as far as possible canned foods 
should be washed, especially if they are to be served without 
heating; and that food should not remain in the can after it has 
been opened. Canned foods that are to be served hot should be 
boiled, if possible without destroying the character of the food, 
for at least ten minutes. Food that is to be served cold direct 
from the can, and food that would be destroyed or made un- 
palatable by such boiling, must be more carefully inspected than 
the food that can be boiled. 

It should be noted that the bacillus botulinus is anaerobic; 
therefore it may not be found on the surface of the jar, while 
below the surface the contents may be loaded with this germ. 
This germ is not frequent in animal food. 

Symptoms of Poisoning. — The first symptoms of poisoning 
are likely to be nausea, vomiting and prostration, soon followed 
by signs of paralysis. Early in the poisoning there is often 
disturbed vision, disturbed speech, and inability to walk. 
The paralysis proceeds, in serious cases, to affect the eye-lids in 
some instances, then the arms, then speech becomes almost 
impossible, swallowing difficult, and finally paralysis of the 
respiratory muscles and death. 

Treatment. — The treatment is to quickly cause vomiting by 
some rapidly acting emetic and then to cause catharsis by large 
doses of castor oil. 

An antitoxin has been produced, and Dickson and Howitt 1 
present their conclusions concerning it as follows: "A true anti- 
toxin may be prepared from the toxin of bacillus botulinus.'' 7 
There are at least two types of this bacillus which are distinct 
as far as their toxin-antitoxin relationships are concerned. In 
the laboratory they find that "the antitoxin may protect against 
the action of the toxin for at least twenty-four hours after the 

1 Journal A. M. A., March 13, 1920, p. 718. 



768 THE PRINCIPLES OF THERAPEUTICS 

administration of one test .dose of toxin, but that the effective- 
ness is, to a certain extent at least, dependent on the amount of 
toxin injected. For therapeutic administration a polyvalent 
antitoxin should be employed, and it should be given in large 
amounts and intravenously." 

TOADSTOOL (MUSCARINE) POISONING 

Muscarine is an alkaloid found in some of the poisonous 
mushrooms, and not infrequently the poisonous mushrooms are 
mistaken for the food mushrooms. 

The symptoms of poisoning are somewhat similar to those 
caused by the over-action of pilocarpine. There is likely to be 
vomiting and abdominal pain, sometimes watery evacuations, 
an increased secretion of saliva, and an increased flow of tears. 
The pupils are generally contracted; there is sometimes dizzi- 
ness and tremors. There may be mucous rales in the chest, and 
dyspnea. If death occurs, it seems to be from prostration and 
from respiratory failure. 

The treatment is to quickly evacuate the stomach and bowels, 
surround the patient with dry heat, and give atropine hypoder- 
matically, strong coffee by the mouth if the patient is not vomit- 
ing, and hypodermic injections of either post-pituitary extract 
or of an epinephrine solution. 

CONVULSIONS OF YOUNG CHILDREN 

Young children have convulsions very easily, as their nerv- 
ous systems are not well balanced, especially if they have inher- 
ited a neurotic taint. If an acute disease is ushered in by a 
chill or by high fever, the young child is likely to have a con- 
vulsion. At other times convulsions are due to digestive dis- 
turbances, probably to some protein poison. Various endo- 
crine gland disturbances may allow convulsions to more readily 
occur, and especially in parathyroid insufficiency and in dis- 
turbances of calcium metabolism. Mild acidosis conditions un- 
doubtedly predispose to convulsions. 

The causes of convulsions may be divided into : (1) Those due 
to cerebral irritation from any disease or from a disturbed metab- 
olism. These are spasmophilic in type. (2) Those due to actual 
inflammation of the meninges. (3) Those due to epilepsy. 



CONVULSIONS OF YOUNG CHILDREN 769 

i . Convulsions of the spasmophilic type are the most frequent, 
and may occur from anything that disturbs or irritates the cen- 
tral nervous system; and meningismus readily occurs in all 
acute conditions in children. Focal infections may be a cause 
of some protein poisoning or of some metabolic disturbance that 
allows convulsions to occur in children, and focal infection is 
more frequently present in children than is supposed. Tonsillar 
and nasopharyngeal inflammations may be a cause of such dis- 
turbances. Also, since it has been learned that the pituitary 
gland frequently changes its size and the amount of its secretion, 
and that the thyroid and parathyroids, even in children, are 
often disturbed, it is not surprising that, with their not well 
balanced nervous systems, children have convulsions with ap- 
parently a slight amount of irritation. In spasmophilic con- 
ditions there is always more or less sleeplessness and increased 
reflex irritability. 

A careful study of the calcium metabolism and of the endo- 
crine gland sufficiency or insufficiency may disclose the cause 
of neurotic, irritable, bad tempered children. 

The nervous reflexes should also be studied; namely, the 
eyes may be in trouble; there may be an elongated, adherent 
prepuce, or an irritated clitoris. There may be serious consti- 
pation; even if there are daily movements of the bowels they 
may be insufficient. The diet may be wrong, which is the most 
frequent cause of nervous disturbances in infants and young 
children; and in young infants vomiting and diarrhea more or 
less rapidly cause acidosis, and convulsions may result. The 
treatment of convulsions in such a patient is carbohydrate food. 

Spasmophilic convulsions are not followed by sleep (as are 
epileptic convulsions), and a child who has this type of con- 
vulsions is also likely to have other signs of spasmodic con- 
ditions, as spasmodic croup, attacks of temper, holding- the- 
breath attacks, bowel cramps, etc., all showing a hyper- 
irritability of the nervous system. Several convulsions of this 
type may occur at short intervals. However, it should always 
be borne in mind that young children can have true epileptic 
attacks, and the possibility of the convulsions being such, must 

always be considered. 

49 



770 THE PRINCIPLES OF THERAPEUTICS 

The treatment of convulsions of the spasmophilic type is 
evacuation of the bowels; the administration of starchy foods, 
as barley water and thin oatmeal gruel; the administration of 
calcium, as lime water or as small doses of the glycerophosphate, 
unless the child can take milk, and best breast milk. Also an 
alkali, as potassium or sodium citrate, should be given, the dose 
depending upon the child's age. 

The sedative required is a bromide, and a safe dose is about 
0.065 Gm. (1 grain) for every year of the child's age, repeated 
every two hours, unless the child is asleep. If the convulsive 
conditions are so severe as to endanger life, a few whiffs of 
chloroform may be necessary. 

It is always of advantage to hold such a child, sitting up r 
in a bath with the water a little warmer than his temperature. 
This takes the blood from the brain and distributes it over the 
body. It is also good treatment when the child is cold and 
good treatment if the child has a high temperature. If the child 
is cold when taken from the bath, he may be wrapped in warm 
blankets, not too tight, allowing his arms to move freely; also 
the extremities and body may be gently massaged. If the child 
is warm and feverish, after the bath he may be placed on a bed 
and covered lightly. 

2. If it is decided that the convulsions are due to actual 
cerebral irritation, localization of serious conditions as in 
the ear, mouth, or throat should be excluded, and the spinal 
fluid should be examined to note what kind of meningeal 
infection is present. The treatment outlined above is good 
treatment for this condition, with perhaps the addition of an 
ice cap to the head for a short time. The high temperature 
should be treated as deemed advisable, depending upon its 
height and the condition of the patient. 

3. As stated, true epilepsy can occur in infancy. It may 
be diagnosed by the type of the convulsion, the coma or sleep 
that follows, and by the bitten tongue; also a careful history 
may disclose petit mal attacks, especially if the child is several 
years old. The family history should be studied, to note the 
conditions that are likely to be inherited, a Wasserman test 
made, and all reflex disturbances of the child must be sought and 



SUNSTROKE 77 1 

treated. It is needless to urge that an epileptic child should be 
individualized, as there is no one method of treatment that is 
advisable for all epileptic children. 

SUNSTROKE— INSOLATION 

Sunstroke is a very serious condition which may develop very 
rapidly, the patient becoming suddenly unconscious, and he 
may die within a few hours, or even within a few minutes. He 
may die comatose, or he may improve somewhat and die of 
heart weakness. If not comatose, he will complain of headache, 
have disturbed vision, be nauseated, dizzy, have a rapid pulse, 
and the temperature may be excessive. 

A patient found comatose who has been exposed to intense 
sun rays or intense heat may not be suffering from insolation, 
and all other causes for the comatose condition must be excluded. 
On the other hand, convulsions followed by coma may be due to 
excessive heat. The various causes of coma and their diagnosis 
have been elsewhere discussed. 

Disease, indulgence in alcohol, and previous attacks of inso- 
lation are predisposing causes. Exhaustion and weariness may 
precipitate a heat stroke, but are more likely to develop heat 
prostration. The excessive temperature of sunstroke may cause 
albumin and casts to appear in the urine. 

Just what is the exact pathologic condition in insolation is 
doubtful except that excessive heat can cause changes in the 
body metabolism, and perhaps cause autointoxication. It has 
been suggested that heat stroke may be a form of uremia, and 
creatinin has been found in excessive amount in the blood. 1 
Post-mortem examinations have shown congestion of various 
organs, and edema of the lungs, brain and meninges. 

Preventive treatment is a proper head protection (and that 
means the air-cooled, large hat), abstention from alcohol in any 
form, drinking of large amounts of cool, not iced, water, and a 
diet largely of carbohydrates, certainly without an excessive 
amount of meat. Patients who are diabetics and those who 
have damaged kidneys should be warned against over-heating 
and exposure to the sun. 

1 Gradwohl and Schisler, Amer. Journ. Med. Sci., Sept., 1917, p. 407, 



772 THE PRINCIPLES OF THERAPEUTICS 

Treatment. — The patient should be immediately taken to the 
coolest possible spot, all tight clothing should be removed, an ice 
cap applied to the head, the temperature taken, the pulse noted, 
and then active cooling treatments inaugurated. If possible, 
the patient should be rapidly transported in an ambulance to 
the nearest hospital where opportunities for the best treatment 
are obtainable. Ice tubbing seems too cruel, and is perhaps 
obsolete. Milder cold applications are advisable. An ice cap 
should remain on the head and a warm water bag at the feet, the 
breeze from an electric fan should be directed over the body, 
and cold water or ice sponging should be done, or sheets wet 
with ice water may be wrapped around the body and frequently 
changed. A thermometer should be placed in the rectum and 
frequently read. If the temperature seems to be rapidly fall- 
ing, active treatment should cease. After a certain amount of 
temperature has been thus abstracted, rather than continue 
this harsher treatment, which may be opposed to nature's 
method of reducing temperature, it might be well to place hot 
water bags about the lower part of the body, cover this 
part of the body with blankets, and allow perspiration to occur. 
The dilatation of the blood-vessels of the abdomen and legs 
may relieve the tension on the head by promoting perspiration, 
nature's method of reducing temperature. If the heart is not 
weak, it might be well to administer a small dose of pilocarpine. 

As post-mortem examinations have disclosed edema of the 
brain and of the meningeal tissues, it might be well to do spinal 
puncture and withdraw a small amount of cerebral fluid. If 
the patient is full-blooded, flushed, and has a bounding pulse, 
venesection would seem indicated. Certain it is that the older 
methods of treatment have not been very successful, and more 
rational treatment must be substituted. 

If the patient seems to rally but the heart begins to fail, 
caffeine, strychnine, and atropine injections suggest themselves ; 
or intramuscular injections of ergot or of pituitary extract may 
be advisable. 

If the patient recovers consciousness and the circulation is 
good, the after treatment is alkaline drinks, starchy foods, and 
prolonged rest, with the administration of plenty of water to 



FREEZING 773 

promote elimination of all toxic products that have accumulated 
in the body. Purging may be at first inadvisable on account of 
the weakness that it causes, but the bowels may be moved daily 
by an enema. 

HEAT PROSTRATION— HEAT STROKE 

This condition presents an entirely different set of symptoms 
from those of sunstroke. It is a collapse that may be fatal, 
and there is likely to be, on recovery, prolonged disability, 
the patient very slowly regaining his circulatory strength. 
In this condition the patient should be moved to the nearest 
cool spot, but should not be transported to a distant hospital; 
all tight clothing should be loosened. As the temperature is 
subnormal, hot water bags should be placed around the body, 
and at the feet, and gentle massage should be given. If there 
is no breeze, an electric fan may be placed over the patient, or 
some one may fan him. 

The treatment is cardiac stimulation with atropine and 
strychnine injections, and coffee by the mouth. An epineph- 
rine solution may be given on the tongue, or a pituitary 
solution may be injected hypodermatically. As soon as the 
patient rallies, he may be carefully transported in an ambulance, 
or on a stretcher, to his home, and best to a cool veranda, and 
he should not exert himself for days. He has suffered a 
circulatory collapse, and the return of his circulatory strength 

will be slow. 

FREEZING 

Frostbite is an acute condition caused by cold, while the 
resulting recurrent condition may be a chilblain. While any part 
is more or less likely to become frostbitten if the circulation 
is poor, still, most frostbites occur from severe chilling of 
exposed parts of the body. There are different degrees of 
frostbite, and the severity of the condition depends upon the 
amount of stagnation of the circulation that has occurred. 
Actual freezing will so interfere with the nutrition of the part 
that blisters will occur, and if the severity of the freezing is still 
greater, the tissue is destroyed and gangrene results. 

The first symptom is loss of sensation, which may not be 



774 THE PRINCIPLES OF THERAPEUTICS 

at first noted. The appearance of the part is pale, and later, 
perhaps, a little bluish. 

The immediate treatment of a simple frostbite should be 
gentle rubbing with the hands and gentle massage of the part 
above the frostbite, to gradually increase the circulation of 
the blood. It is inadvisable to apply heat to the frozen area. 
As soon as the circulation improves there is burning and some- 
times itching, and the part feels very uncomfortable, even at 
times painful. If the skin has been injured and blisters occur, 
they should be carefully dressed and protected, much as are 
burns. If there is much moisture, saturated solution of boric 
acid applied as a wet dressing is a most efficient treatment. 

If an extremity, or a part of it has been frozen, it should 
be kept cold or cool for some time; i.e., the rest of the patient 
should be kept warm, but the affected area should not be 
subjected to a warm atmosphere, and gentle friction with a 
towel wrung out of cold water is advisable. The limb should 
then be elevated, to encourage the return circulation. Later 
the room may be at the ordinary temperature, and the frozen 
part may be covered with gauze. Blistered skin should be 
treated as above suggested. 

If the circulation of the frozen area does not return and gan- 
grene develops, then the extremity should not be elevated, as 
absorption from the disintegrating tissue should not be en- 
couraged. Unless there are symptoms of absorption of toxins 
it is well to wait before amputating until the fine of demarcation 
between healthy and gangrenous tissue has thoroughly formed. 
During this gangrenous period no treatment should be used that 
encourages moisture; the drier the gangrene, the less danger of 
infection. If the gangrene becomes moistened, powders, as 
boric acid, should be applied to encourage dryness. The 
proper time to amputate must be decided by medical and 
surgical consultation. 

SEASICKNESS 

There is no one cause for seasickness. Doubtless there are 
several factors producing this condition, the most important of 
which is probably a disturbance of the lymph in the semicircular 



SEASICKNESS 775 

canals of the internal ear, and an inability to establish equilib- 
rium when the individual first leaves the steady earth for the 
unsteady water. Another important factor is doubtless the 
blood-pressure. The blood-pressure may first be increased, by 
the effort of the vasopressor glands to sustain the tension and 
prevent the disturbance. Soon, however, the blood-pressure 
falls, and as soon as nausea is present there is considerable 
lowering of the pressure and more or less weakening of the heart. 
Another factor in the production of seasickness is doubtless the 
effect on the eyes of the moving water, and moving objects 
cause in some people very decided reflex disturbances. Pre- 
disposing causes to seasickness are digestive disturbances due to 
a bad condition of the alimentary canal, or to over-eating, and to 
remaining in a bad atmosphere in a cabin. 

Preventive treatment is to take a purgative twenty-four 
hours before going aboard the steamer, and during this twenty- 
four hours to eat very moderately of the simplest kind of food, 
and let the first two meals on board be very simple. If the 
blood-pressure is low, it is well, for two or three days before 
going on board to take digitalis, and perhaps a few doses of 
strychnine. The individual should remain on deck as much as 
possible, and keep his eyes (properly protected from too bright 
sunlight) on objects that are not moving. In other words, he 
should not face the water. 

If nausea and a feeling of faintness develop, black coffee 
atropine and strychnine should be given and the patient should 
lie flat in the open air. If the patient is too ill to remain on deck, 
if possible the port hole should be open in his stateroom, so that 
he may receive plenty of fresh air. A tight abdominal bandage 
should be applied to aid in raising the blood-pressure. If 
needed, atropine should be given hypodermatically, ergot in- 
tramuscularly, and epinephrine solutions on the tongue. As 
soon as possible, warm, thin, starchy foods should be taken. 

Although bromides have been lauded and suggested as a treat- 
ment for seasickness, such medication does not seem advisable, 
unless the individual has a high blood-pressure. In that 
case bromides and hot foot-baths might relieve the cerebral 
disturbance. 



PART XII 

TREATMENT OF SIMPLE DISTURBANCES OF THE 
SURFACE OF THE BODY 

THE RELATION OF THE SKIN TO THE SYSTEMIC CONDITION 

The skin is an indicator of the health of the individual and of 
the physiologic condition of the internal organs. It is soft and 
moist when there is normal thyroid secretion; over-moist and 
flushed in hyperthyroidism; dry and harsh in hypothyroidism; 
dark from diseased suprarenals; hairy from some forms of 
pituitary and suprarenal disturbance; dry from kidney in- 
sufficiency; blue and mottled from cardiac insufficiency; pale in 
anemia; flushed in plethora; cyanosed in lung insufficiency; 
yellow in bile obstruction; develops an acne in adolescence and 
in intestinal disturbances; develops erythema, urticaria, papules 
or pustules in drug and food poisoning; develops boils from focal 
infections; and is locally diseased from irritants, poisons, and 
infection. The skin, especially of the face, neck, and backs of 
the hands, shows the age, and the age is that of the skin; i.e., it 
shows poor health and chronic disease. 

The drugs that most frequently cause erythema of the skin 
are antitoxin, arsenic, belladonna, copaiba and other balsams, 
salicylic acid preparations, synthetic salts, volatile oils and 
drugs containing them, and occasionally opium and quinine 
preparations. Chloral may cause all kinds of eruptions, bro- 
mides pustular eruptions, and iodides papular eruptions. 
Drugs that cause eruptions only after their absorption from the 
alimentary canal are not as likely to cause itching as drugs that 
produce eruptions through irritation of the gastrointestinal 
tract, more especially of the duodenum. 

The foods most likely to cause irritations of the skin are 
fish, and especially shellfish, the condition being due to protein 
poisoning. Many people cannot eat strawberries without 
having erythematous and urticarial eruptions on the skin, due 
to a slight irritation of the gastrointestinal mucous membrane. 

776 



ITCHING — PRURITUS 777 

Many foods cause poisoning only in certain conditions of 
the alimentary tract and in certain conditions of the blood. 
The blood may at certain times contain substances that for 
the moment are harmless, but that are likely to produce 
protein poisoning when certain other substances reach the blood. 
Also many foods and drugs may not cause skin reactions or 
symptoms of any poisoning when the liver and kidneys are 
intact, but if either is diseased poisoning more or less readily 
occurs. This is particularly true with liver insufficiency, as the 
liver detoxicates many otherwise irritating substances, particu- 
larly the alkaloids of many drugs. The greater activity of 
drugs administered hypodermatically is due to the fact that 
they do not pass through the liver and therefore are not partially 
neutralized as they are when administered by the mouth. 

The interrelation of the skin and kidneys is an interesting 
physiologic fact. If the skin is dry and cannot secrete, or, if 
it is seriously inflamed as in scarlet fever or in general erysipelas, 
more work is thrown on the kidneys and congestion readily 
occurs, and albuminuria and even nephritis may result. On the 
other hand, if the kidneys are chronically diseased and the skin 
properly secretes, the patient is not readily poisoned. But 
if the skin becomes dry and does not properly secrete, the 
patient is quickly poisoned and the disease of the kidneys soon 
becomes fatal. Patients with dry, insufficiently acting skin, 
whether of the ichthyosis type or of the dermatitis exfoliativa 
type, are likely to develop kidney disturbances. With serious 
burns of the surface of the body there is likely to be duodenal 
inflammation and more or less kidney disturbance. 

ITCHING— PRURITUS 

Itching may occur with any irritation of the skin, and is very 
frequent in disease of the liver and in insufficiency of the 
kidneys. A jaundiced patient is always troubled with pruritus, 
which is caused by the attempt of the skin to excrete bile 
pigments and more salts than usual. In this condition one of 
the most efficient treatments is frequent warm, alkaline baths, 
to dissolve and wash off the irritating crystals that collect on 
the surface of the skin. 



77^ THE PRINCIPLES OF THERAPEUTICS 

Focal infections can cause itching of different parts of the 
body, and even a chronic appendicitis may cause perineal and 
genital itching which ceases on removal of the appendix. Other 
localized itchings often cease when the focal infection is removed. 
A frequent cause of itching is intestinal worms, and localized 
itching of the anus and perineum is often due to pinworms. 
Abnormal sweatings and secretions from sinuses or infected 
areas may cause itching. 

Treatment. — It is almost superfluous to urge that a cause for 
the itching should be sought, and if possible, removed, and that 
local causes should be radically treated. Any particular food 
or drug that causes pruritus should of course not be taken. 
Sub thyroid secretion is a cause for itching, and when that condi- 
tion is present the administration of small doses of thyroid is 
curative. 

Acute pruritus, like protein poisoning and urticaria, should 
primarily be treated as follows : All food should be temporarily 
stopped; a quickly acting purgative given, either castor oil or a 
saline; an alkali should be given, as sodium or potassium citrate, 
in 2-gram (30-grain) doses every three or four hours until the 
urine is alkaline, or the bicarbonate of sodium may be given in 
i-gram (1 5-grain) doses every three hours ; large amounts of water 
should be drunk; and alkaline baths should be taken. If it is 
presumed that the cause was irritation of the gastrointestinal 
tract, it is well to give bismuth subcarbonate with sodium bi- 
carbonate for several doses. 

Another cause of itching is a disturbed metabolism, and if 
there is muscle and nerve irritability it may show parathyroid 
disturbance. These patients often are improved by the adminis- 
tration of calcium in some non-irritant form, as lime water, or 
as calcium glycerophosphate, or better, if there is no contra- 
indication, as milk. 

The diet for some days for these poisoned individuals should 
be milk (if it agrees) or cereals. Later vegetables and fruits 
that are known not to cause irritation may be given, and 
finally animal proteins in small amount, i.e., meat once a 
day, if it is known that meat ordinarily causes no disturbance. 

Local applications, besides the alkaline baths and drying 



PRURITUS VULVAE 779 

of the skin with soft towels used mop-like and not by rubbing, 
should be cooling powders, and nothing is better than 
cornstarch. Severe local itchings are always benefited by 
bicarbonate of sodium solutions, alcohol or cologne sprays, 
3 per cent, phenol solutions, i per cent, menthol solutions, 
and spirit of camphor. Or localized spots of irritation may 
be painted with the syrupy mixture produced by rubbing cam- 
phor and chloral together, in equal parts. In general itching 
the underclothing should be of silk or linen, and if the weather is 
cold, such flannel or thicker garments as are needed may be 
put on over them. 

It is hardly necessary to urge that all skin parasites must 
be excluded; all poisoning by plants or poisoning by vapors or 
irritants received during the individual's work must be pre- 
vented and excluded. There is generally some removable 
cause for acute and subacute localized eczema, if it can be found. 
General eczema is probably most frequently caused by some 
internal disturbance. 

In all itching conditions the animal proteins should for a time 
be excluded from the diet, and in inveterate cases the skin pro- 
tein tests should be made to determine, if possible, what pro- 
tein poison is causing the irritation of the skin. 

PRURITUS VULV.E 

The cause of this very troublesome irritating condition must 
be sought. It may be due to an irritating discharge from the 
vagina, to a fissure, to a fistula, to an eczema, to diabetes, or to 
pinworms or other parasites. It may also be reflexly due to 
some focal infection, and chronic appendicitis is occasionally a 
cause of the condition. 

Applications of yeast, alkaline lotions, and menthol solutions 
may be of value. Sometimes painting with iodine is curative, 
and sometimes the high frequency electric currents are valuable. 
At times, especially if there are irritating exudations from the 
glands of the region, the best cure is by means of the x-ray. 
Bathing the parts with water and soap is often inadvisable, and 
alkaline washes or almond or other bland oils for cleansing are 
preferable. 



780 THE PRINCIPLES OF THERAPEUTICS 

URTICARIA 

The treatment of urticaria is on the same plan as above out- 
lined for acute pruritus, and the cure is generally rapid. The 
treatment consists of a cathartic ; abstention from food ; drinking 
plenty of alkaline water, as a Vichy, artificial or natural; the 
administration of alkalies, and often of calcium ; and local appli- 
cations of powder, and alcohol or menthol sprays. In urticaria, 
baths are often not advisable, as there is likely to be more itch- 
ing after bathing. 

So-called "giant urticaria" shows serious poisoning, and 
added to the above treatment should be large doses of either 
quinine or antipyrine, alkalies to the point of alkalizing the 
urine, and a calcium. The cause of the " giant urticaria " should 
be sought and the patient, if possible, not again subjected to the 
probability of another attack. 

Angioneurotic edema is very closely associated with so-called 
giant urticaria. Sometimes the condition is very serious, espe- 
cially if it occurs in the mouth and throat. It is probably always 
due to some intestinal disturbance, often a protein poisoning, 
or to poisoning from some localized infection. One of the most 
successful immediate treatments is epinephrine, either given 
hypodermatically, or as a soluble tablet, or in solution, on the 
tongue. When this condition occurs in the mouth and throat, 
suffocation may be caused, and the patient is safer in a hospital 
where tracheotomy, if needed, can be done. After the attack 
is over a focal cause should be sought, and if none is found, 
various protein and food tests should be made to prevent, if 
possible, a recurrence of this condition. 

MOSQUITO BITES 

To prevent the bites of mosquitoes a few drops of the follow- 
ing mixture may be placed on the face and hands: 

Oil of cedar 5 mils 

Spirit of camphor 10 mils 

Oil of citronella 10 mils 

A drop of the spirit of camphor, a strong menthol solution, 
alcohol, strong ammonia, or a 5 per cent, phenol solution, will 



IVY POISONING 781 

generally prevent the itching, when applied to the bite of any 
insect. 

A solution of sodium salicylate 1 Gm., formaldehyde solu- 
tion 1 mil, and water up to 100 mils will attract and kill flies. 

IVY POISONING 

The poisonous juice of the Rhus Toxicodendron (poison ivy, 
poison oak, mercury) is the same as that of poison sumach, and 
a very minute portion may cause an inflammation of the skin. 
This poison, toxicodendrol, is contained in the leaves, is of a 
resinous nature, and is non- volatile, in spite of the declaration 
by many susceptible individuals that they cannot pass by a 
plant without being poisoned. Therefore, direct or indirect 
contact must occur. The hands and face of course are the 
parts most affected, but it is easy to transplant the irritant by 
the hands to other parts of the body. The softer and more 
pliant the skin, the quicker does the irritation develop, and 
a minute amount of the resin will cause vesication. While 
most individuals are susceptible to this common poison, some 
can handle it with impunity without danger of poisoning. 
Some few individuals do not develop symptoms of poisoning for 
several days after exposure to the plants. 

Internally the rhus toxicodendron, which has been unneces- 
sarily termed a drug, and was formerly officialized in the 
Pharmacopoeia, is, except in minute doses, an irritant and a 
poison. Symptoms after absorption are dilated pupils, faint- 
ness, irregular pulse, increased perspiration, muscle weakness, 
tremblings, and even convulsions. Later symptoms are those 
of kidney and bladder irritation. 

Protections against poisoning from the ivy are rubber gloves 
and fats or oils smeared over the parts of the body which 
might be exposed to contact with it. If contact with this 
plant is known to have occurred, immediate washing the exposed 
parts with hydrogen dioxide solution, then scrubbing with soap 
and water, then with equal parts of alcohol and water, and later 
(after the thorough cleansing of the exposed parts) a hot bath 
is the preventive treatment advisable. It must be noted, 
however, that the outer clothing may carry the irritant poison, 



782 THE PRINCIPLES OF THERAPEUTICS 

and hence a thorough brushing and perhaps washing of the 
clothing is advisable. 

When the inflammation has occurred, the patient should be 
treated much on the plan, as to catharsis, diet, and alkalies, as 
though he had an acute urticaria. A useful lotion is magnesium 
sulphate, in strong solution. It is not often advisable to use 
the lead solutions so long recommended, as, if there is an 
abrasion, poisoning may occur. Besides mopping on the 
magnesium sulphate solution, powdered cornstarch applied to 
the inflamed area is advisable. Ichthyol preparations have 
been recommended, but are no improvement on the above 
simple treatment. If blisters occur, they should be treated as 
burns. The duration of the inflammation varies from a few 
days to nearly two weeks. 

PRIMROSE POISONING 

It is not generally recognized that the primrose can cause 
an acute inflammation of the skin resembling an acute eczema, 
and many patients are treated for eczema while the cause 
remains active in their house or garden, and the inflammation 
persists. It is the hands and arms that are most affected by 
this plant, and many a cure has immediately occurred when 
the plant was removed from the house. The irritation occurs 
only from contact. The treatment is the same as for any 
other acute eczema, but it is not permanently successful until 
the primrose is abolished, and all contact with the plant ceases. 

ECZEMA 

This common, multiform, troublesome disease of the skin 
requires investigation of the diet, of the excretions, of the 
ductless glands, of the clothing, and of the hygienic surround- 
ings. Some foods and some drugs cause eczema in susceptible 
individuals. External poisonings are a frequent cause of eczema 
of the hands and face. 

The eczema of children is a study in itself. The proper 
diet for a child with eczema cannot be outlined; the child must 
be studied. Many times too much fat has been given; at other 
times too much sugar; at other times too much cereal. Consti- 



CHAPPED HANDS 783 

pation in a child may be a cause of eczema, and insufficiency of 
thyroid secretion may cause moist eczemas in young children 
and dry eczemas in old age. The seborrheic eczema of the 
scalp of infants requires skilled treatment by one who has 
made a study of this subject. Again no one treatment is 
always successful. Some forms of eczema require local 
sedatives, and some local stimulation. 

A much used sedative is Lassar's paste, and a satisfactory 
formula is: 

Salicylic acid 1 Gm. 

Zinc oxide 10 Gm. 

Starch 10 Gm. 

Petrolatum 25 Gm. 

There are various other sedative ointments, and various 
sedative powders, as noted in the first part of this book under 
the headings of " Dusting Powders" and " Emollients. " 

The stimulating ointments vary, and consist mostly of oil of 
cade, ichthyol, sulphur, and resorcin in various combinations. 
Which preparation is best and what strength is advisable can 
only be determined by the kind of eczema and the susceptibility 
of the skin to stimulation. 

CHAPPED HANDS 

Chapping of the hands is due to cold weather and an insuffi- 
cient amount of oil or fat in the skin, and in cold weather the 
sebaceous secretions of the skin are at a minimum. Chapping 
may also occur from irritation of a dry, chilled skin. 

The preventive treatment is to keep the hands warm, and to 
rub on some bland oil or fat; cold cream and other animal fats 
are very satisfactory. Wool fat thinned with oil and water 
makes a good ointment for the dry skin of the hands. Some 
skins will tolerate glycerin in from 30 to 50 per cent, strength, 
while on other skins even dilute glycerin will cause irritation. 

Gelatinous lotions are often very satisfactory, and quince- 
seed lotions are much used. A useful preparation is made by 
melting 1 Gm. of white wax with 4 Gm. of spermaceti and 15 
mils of almond oil, and gradually adding 10 mils of glycerin, 



784 THE PRINCIPLES OF THERAPEUTICS 

gently triturating, and then allowing to cool. Pusey suggests a 
tragacanth lotion as follows: 

Tragacanth 4 Gm. 5i 

Boric acid 12 Gm. 5iii 

Glycerin 30 mils or fl. gi 

Water enough to make 500 mils (a pint) ad Oi 

Any perfume may be -added to suit the individual desire. 
The boric acid, glycerin and water are mixed, and then the tra- 
gacanth gradually added, and the mixture shaken until it has 
dissolved. This combination makes a thick mucilage, but it 
can be made thinner by using less tragacanth. 

This preparation or some other mucilagenous lotion may be 
used to cleanse the hands, as soap makes chapped hands worse. 
Water, unless it is softened with bicarbonate of sodium, boric 
acid, or borate of sodium, is irritant to all eczemas as well as to 
chapped hands. . 

CHILBLAINS 

Chilblains develop in cold weather in parts where the circula- 
tion is impaired or is insufficient. They frequently occur on 
the feet, especially if the shoes are tight, or they may occur on 
the fingers when the gloves are too tight, and can occur on any 
exposed part of the body, as the nose or ears. A part once 
chilled or suffering from chilblain is always more or less sus- 
ceptible to cold, and recurrences readily occur. The unpleasant 
sensations are heat, burning, sometimes itching, and always 
more or less redness. These symptoms are likely to be worse 
when the individual goes into a warm room or becomes warm in 
bed. Sometimes the part may be quite inflamed, even to the 
extent of a mild subacute dermatitis. If the part is cold, brisk 
rubbing is of advantage, or putting the part into hot water bene- 
fits, i.e., anything that stimulates the circulation is of advantage. 
If the part is burning and hot, then it should be cooled. Some- 
times the application of equal parts of tincture of iodine and 
tincture of opium is very soothing; also diluted glycerin and 
menthol preparations may soothe the parts. Any part that has 
the circulation impaired, as the toes and the feet, is improved by 



ACNE 785 

exercise; therefore not only massage, but exercise and use of 
the part of the body that has been chilled will tend to make the 
circulation better, cause better nutrition, and therefore less 
likelihood of a recurrence of the chilblains. Warm clothing of 
the susceptible parts of the body, as warm mittens and warm 
stockings, is preventive of this disturbance. The patient's 
general condition should be improved, and circulatory stimu- 
lants, iron, and extra food are often advisable. Electrical 
treatment that warms and stimulates the chilled part is often 
of benefit. 

Sometimes chilblains and a burning sensation of a part, or 
blanching of a part with later burning and increased heat, is due 
to Raynaud's disease, and a subthyroid condition often predis- 
poses to chilblains. If breaking down of tissues occurs, the 
treatment is the same as that for blisters and ulcerations from 
blisters. If the skin is irritated, the same soothing lotions that 
are suggested for chapped hands are of benefit. 

ACNE 

It should be remembered that acne has been shown to be due 
in very many instances to the acne bacillus; also that intestinal 
putrefaction and toxins absorbed therefrom, and the toxins pro- 
duced by the colon bacillus are predisposing and promoting 
causes of acne on any part of the body, and particularly on the 
face. It is necessary to correct all of the various functions of 
the body as well as to properly treat, locally, acne of the face. 
A disturbance of the menstrual function in young girls seems to 
be a particularly frequent cause of acne; and the age of puberty 
in boys seems to be a period when acne is frequent. Good 
healthy cleanliness of the face is essential in the cure of acne 
and the prevention of so-called "black-heads." Too hot water 
and too cold water used on the face may predispose to, or per- 
petuate, an acne. 

The exact local treatment is so varied, added to the 

necessary individual determination of the proper diet and the 

proper care of the bowels, that it cannot be outlined here. 

An acne patient should be studied by his physician or by a 

dermatologist. 
50 



786 THE PRINCIPLES OF THERAPEUTICS 

IMPETIGO CONTAGIOSA 

This infection of the skin is very frequent, and is generally 
caused by a staphylococcus. Multiple infections are caused by 
transplantation. 

When treated properly, this disease is quickly cured. It is 
essential that the scabs be softened with warm oil or with an 
alkaline wash, as bicarbonate of sodium water, and that all the 
crusts be removed, burrowing of the pus is thus prevented. The 
areas under the scabs should be thoroughly washed with perox- 
ide of hydrogen solution and later cleaned with sodium bicar- 
bonate solution, after which treatment ammoniated mercurial 
ointment, Unguentum Eydrargyri Ammoniati, which contains 
10 per cent, of ammoniated mercury, should be applied in full 
strength, if there are not too many purulent spots. If there are 
many spots, the official ointment should be diluted one-half with 
petrolatum. If it is a young child's skin that is to be treated, a 
1 per cent, solution of ammoniated mercury in some bland oil, as 
almond or olive oil, may be used. 

If this infection occurs in the hair, the part should be cleaned 
as above, and then the region may be soaked in this 1 per cent, 
mercurial solution of oil. 

It is needless to urge that to prevent re-infection the body 
should be thoroughly washed and then sponged with boric acid 
solution, and only clean, non-infected clothing should be worn. 
If the disease occurs on the hairy parts of the body, a thorough 
washing with boric acid solution is the best treatment, and the 
mercurial ointment may be applied to the spots. 

STY— HORDEOLUM 

A sty is ordinarily a staphylococcic infection, and is caused by 
anything that carries infection to the eye-lids, as dirty towels 
or dirty hands. Irritation of the eye-lids, caused by errors of 
refraction, promote the development of stys. 

It is difficult to abort a sty, and consequently applications 
of warm boric acid solution may hasten the development of the 
drop or two of pus, which, as soon as the yellowish spot is seen, 
should be evacuated, and the warm boric acid eye washes con- 



BOILS 787 

tinued. Cleanliness should be urged, and the occasional use of 
boric acid solutions. The general nutrition of the patient often 
requires improvement, and an examination of the refraction to 
ascertain if the patient needs glasses, or, if he has glasses to 
determine if they are correct, is advisable. 

BOILS 

Boils are always due to infection, sometimes from an external 
and many times from an internal source, and a focus of 
internal infection should be carefully sought whenever crops of 
boils occur. The source of infection may be in the nose, nasal 
sinuses, tonsils, teeth, or gums; or there may be a suppurating 
ear, or some other localization of infection. The germ that is 
most frequently the cause of boils is the staphylococcus pyogenes 
aureus. 

When a boil starts it is sometimes possible to abort it by 
applying to the inflamed area, every two or three hours, a 25 
per cent, solution of menthol in ether. An older abortive 
method has been to inject into the swollen area a drop or two of 
liquid phenol, or 1 mil of a 2 per cent, solution of phenol. Un- 
fortunately, many boils cannot thus be aborted, as they are 
generally too far advanced when first seen. 

If the boil is positively developing, it is well to hasten its 
development by a poultice made of gauze wet with a warm 
solution of alcohol (1 part of alcohol to 3 parts of water), 
covered with oil silk, and strapped or bandaged firmly over the 
boil. This gauze should be kept constantly wet. If the sur- 
rounding skin becomes irritated, it should be covered with 
petrolatum or boroglycerin. Strong antiseptics should not be 
used on the skin to destroy or injure it, and certainly iodine 
should not be used. The only use for iodine is on the parts 
somewhat removed from the boil which may show, if the 
region is hairy, a tendency to infection of the hair follicles, but 
the iodine applications should not be repeated often enough to 
cause inflammation. 

When pus is diagnosed as being present, the skin should be 
incised, the pus evacuated, and the wet dressing continued, 
with some soothing ointment or fat spread over the surround- 



788 THE PRINCIPLES OF THERAPEUTICS 

ing skin, so that irritation and new points of infection may not 
occur. There should be no squeezing of the boil, although the 
dead tissue and clumps of pus may be gently removed with for- 
ceps through the opening or incision. The dressings should be 
done frequently, two or three times a day, depending upon the 
tendency for the opening to plug up and thus prevent good 
drainage. It is sometimes well to put in a small drain. 

The general treatment of the patient is important. It not 
only should be ascertained if there is any focus of infection, 
but also whether or not there is diabetes, or any other chronic 
condition that would promote the development of boils or 
prevent healing. Careful cleanliness of all parts of the body 
must be insisted upon. Nutritious food should be given, and 
often tonics, especially iron, are advisable. 

One of the best treatments for multiple boils is yeast. From 
one- third to one-half of a yeast cake dissolved in a glass of 
water and taken once or twice a day seems to aid in shortening 
the course of the infection. This makes a not unpleasant sour 
drink, and generally the yeast will cause better movements of 
the bowels. If too frequent movements are caused, the 
amount of yeast should be reduced. The treatment should be 
continued for many days, and sometimes for many weeks. 
It is as successful as the internal administration of sulphur, 
which has been so many times recommended. Sometimes 
arsenic given for a long time will stop the recurrence of boils. 

Vaccine treatment, either stock or autogenous, has been 
many times apparently successful, but seems to be no more 
frequently successful than is the treatment by yeast. 

CARBUNCLES 

Carbuncles are really multiple boils, and the necrosis, or 
core as it is sometimes termed, is greater than with boils. 
Generally there are multiple openings, if the carbuncle is allow- 
ed to suppurate through the skin. They occur more frequently 
in men than in women, and very frequently on the back of the 
neck, perhaps because this region is kept less clean, and is 
more or less chaffed and irritated by coat collars that are 
dirty and carry infection. 



PSORIASIS 789 

The same investigations should be made as when boils occur, 
as to whether or not there is focal infection and to ascertain 
the general condition of the patient. Carbuncles of the neck 
are always more or less dangerous, as they may cause a phlebitis, 
extending to the blood vessels of the cranium, and also there is 
the danger of emboli. Multiple infections and general 
septicemia may occur from carbuncles. 

The carbuncle is treated much on the same plan as is the boil, 
and when pus is diagnosed it should be freely opened; drainage 
is essential. Much manipulation of a carbuncle is inexcusable, 
as tending to prolong and increase the local infection, and to 
cause absorption into the blood vessels and lymphatics, and, 
consequently, a general distribution of septic material. As 
soon as the necrotic tissue has been entirely evacuated, the wet 
dressings should be changed to dry dressings, with frequent 
cleansings with saturated solutions of boric acid. 

The same general treatment outlined for recurrent boils is 
often advisable for carbuncles, although a single carbuncle may 
occur without any association with internal infection or boils. 

PSORIASIS 

It is not intended to really suggest a treatment for this 
troublesome chronic condition, but to note that the cause of the 
condition has not been determined; that it seems very impor- 
tant to seek, and to eliminate, if possible, focal infection; that 
bowel putrefaction should be prevented; and that sometimes 
a diet without meat for a time is advisable. Lactic acid bacilli 
are of benefit in changing the flora of the intestines. The 
bowels should move daily and freely, and colon washing is 
sometimes advisable. 

Arsenic internally has long been a treatment for psoriasis, 
and generally it will cause improvement, but will not prevent 
recurrences. It would seem that a drug, that acts so generally 
on the whole system and on the skin as a whole, in order to be of 
benefit to these localized lesions must have some action on the 
cause of the disease, which as yet has not been discovered. 
In other words, if psoriasis were due to a germ, arsenic could 
certainly be of benefit. There has been no proof that a 



79° THE PRINCIPLES OF THERAPEUTICS 

vaccine treatment is valuable, even if an autogenous vaccine 
is used. 

Whatever other treatment is instituted, local treatment 
seems to be essential, and apparently none is better than a 2 per 
cent, chrysarobin ointment, used until distinct reaction has 
occurred, and then sedative ointments may be used. The 
official ointment of chrysarobin, Unguentum Chrysarobini, is 
6 per cent, in strength. 

RINGWORM— TINEA TRICHOPHYTINA 

Ringworm may occur on any part of the body, and it is most 
inveterate and hardest to heal in the variety that occurs in the 
hair or on the scalp. It is due to a fungus growth, and there- 
fore requires germicidal treatment. 

The part of the body affected should first be scrubbed (unless 
it is a young child) with green soap to remove all the scales of 
the region and cleanse the surrounding skin. Painting the 
ringworm itself with tincture of iodine is often sufficient, if this 
is repeated on several days, or a 10 per cent, solution of Liquor 
Formaldehydi may be swabbed over the part and allowed to dry. 
Subsequent applications for a few days may be made with the 
official ointment of ammoniated mercury. The age of the 
patient and the texture of the skin must always be considered 
in determining the strength of the germicidal preparations to be 
used. 

If ringworm occurs on the hairy portions of the body, the 
general scrubbing should be the same, and a 1 per cent, solution 
of ammoniated mercury in almond oil may be used on the parts 
around the infection. All of the loose hairs of the infected 
area should be removed and the lesions then treated as suggested 
for the non-hairy parts of the body. The infection is very 
difficult to cure on hairy parts, and especially on the scalp, and 
the most rapid cure is caused by exposure to the x-ray. One 
or two treatments by radiation will cause the hair of the part 
to fall out, but the disease will be eradicated, and new hair soon 
grows. This same treatment is of value when ringworm, 
" barber's itch," occurs in the beard. 



ITCH — SCABIES 79 1 

TINEA CRURIS 

This occurs most frequently among young men on the upper 
part of the thighs, on the perineum, on the buttocks, and some- 
times on the scrotum. It is very persistent under most treat- 
ments, and is likely to occur from dirty suspensory bandages 
used by those who take part in athletics. This infection is 
rapidly transmitted from one to another by the carelessness of 
infected men in the use of toilets. 

The most successful treatment is that which insists upon 
complete surgical cleanliness. The patient should come to the 
office for treatment bringing a clean set of underclothing. The 
affected areas and the regions surrounding them must be 
thoroughly cleansed with surgical antiseptic soap and water, 
and all the surrounding dry epidermis should be carefully re- 
moved, care being taken not to break the skin. A swab of 
cotton is next wet in the official formaldehyde solution, full 
strength, and is lightly and quickly swabbed over the affected 
areas. The patient should then be encouraged to endure the 
burning pain for three or four minutes, at the end of which time, 
or sooner if necessary, the part is swabbed with water. If the 
pain is still intense after a few minutes more, a 3 per cent, 
solution of phenol may be swabbed over the part. Soon the 
burning has ceased, and the skin may be gently dried, and then 
thoroughly covered with talcum powder, or better, with a 
starch and boric acid powder, equal parts. The patient should 
report in twenty-four hours for observation, and if any severe 
inflammation has been caused, which is rare if the above tech- 
nique is carried out, some sedative ointment may be applied, 
perhaps best a 2 per cent, phenol ointment. At the end of a 
week the patient should be again examined, and any suspicious 
areas should be treated in the same manner. This method 
will generally cure this kind of ringworm in two weeks, at most. 

ITCH— SCABIES 

This disease is caused by the itch mite, which is not of such 
infrequent occurrence, even among cleanly people, as is gen- 
erally supposed. Some individuals are tolerant to the irritation 
from this parasite, and do not develop annoying itching; con- 



792 THE PRINCIPLES OF THERAPEUTICS 

sequently they may unwittingly harbor the disease and trans- 
mit it to others. Other individuals are so greatly annoyed by 
it that they quickly seek aid. 

The burrow which is made by the female most frequently 
occurs between the fingers, but may occur on other parts of 
the body, on the elbows, or on the nipples, and sometimes more 
or less all over the body. When they occur on the legs, back 
and abdomen, scratch marks will always be found. Sooner or 
later, an eczema generally develops, or even small infected areas 
may occur, due to the scratching. 

Many times the diagnosis is readily made; at other times the 
patient is treated for everything except for a parasitic disease. 
Scrapings from the burrows placed under a microscope will 
disclose either the mite or its eggs, if the disease is present. The 
parasite seems to be most readily transmitted by sleeping with 
an infected bed-fellow or in an infected bed, and of course it is 
readily transmitted by an interchange of infected clothing. 

The preparation for the treatment consists of a hot bath 
with good strong soap, as ordinary laundry soap, and a thorough 
scrubbing with a nail brush of all infected areas, so as to open 
up the runs of the parasites. Then a sulphur ointment should 
be rubbed into the infected regions. The official Unguentum 
Sulphuris contains 15 per cent, of sulphur, and as this is too 
strong for most skins it should generally be diluted with an 
equal part of simple ointment (Unguentum). This treatment 
should take place just before bedtime, and after the treatment 
the individual puts on clean, old pajamas. On the following 
morning he puts on clean underclothing and thoroughly cleaned 
or positively non-infected outer garments. 

This treatment is repeated for three successive nights, using 
the same ointment-besmeared pajamas. Each morning the 
patient may bathe for cleanliness. At the end of a week 
another treatment should be taken. Generally the scabies will 
be cured by this method. A more pleasant method of using 
sulphur is to dust washed sulphur over the body, rubbing it 
into the infected regions. 

Another successful treatment for scabies is with balsam of 
Peru. This may be used pure and rubbed into the parts which 



HEAD LICE 793 

have been cleaned by scrubbing; or a combination is sometimes 
advisable, as precipitated sulphur 2 Gm. (30 grains), balsam of 
Peru 10 mils (2% rluidrachms) and petrolatum 30 Gm. (1 
ounce) . 

Many other antiseptics have been used, as betanaphthol and 
cresol solutions, but none is better than those above described. 

HEAD LICE— PEDICULOSIS 

This condition, frequent among certain classes of school 
children and in those living in dirty tenements, has long been 
treated with kerosene oil, the kerosene being applied to the whole 
head and scalp, which is then covered for twenty-four hours. 
The dead lice are later removed with a fine tooth comb, great 
care being taken to clip out the nits. Of course the most 
satisfactory, quick treatment, if the patient is a boy, is to cut 
the hair close to the scalp. 

More recently xylol has been suggested as a strong parasiti- 
cide. This colorless coal-tar liquid will burn the skin and scalp 
somewhat, but will not cause blistering, and seems to be death 
to the lice and their ova. Xylol is inflammable; therefore it 
should not be used near a fire or when there is artificial light 
other than electric. Sometimes xylol is diluted with an equal 
part of ether, but it is thus rendered no more efficient. A 
cotton swab is made and soaked in the solution or mix- 
ture, and then the scalp is gone over very thoroughly, and 
the strands of hair are pulled through the soaked cotton. 
Generally one or two treatments are sufficient to eradicate the 
parasites. 

If scratching has caused eczema, or there are impetigo conta- 
giosa spots, these conditions should be later treated, after the 
eradication of the lice. After the first radical treatment, the 
hair should be thoroughly washed on the following day, and 
then an ointment suggested, by J. E. Lane, of xylol (xylene) 
4 mils (1 fluidrachm) and petrolatum 30 Gm. (1 ounce) may be 
applied to the irritated parts of the scalp that may be supposed 
to harbor the parasites. 

The same xylol treatment is successful in eradicating lice 
from the pubic region or the axillae. 



794 THE PRINCIPLES OF THERAPEUTICS 

HAIR 

To perpetuate a growth of healthy hair requires good 
common-sense treatment. Ordinarily a shampoo once a 
month, or more frequently if the hair is subjected to dust and 
dirt or if there is much sweating of the scalp, is advisable. 
Daily good combing and proper brushing is also necessary. If 
for any reason the circulation of the scalp is not good, scalp 
massage, or rubbing the scalp is necessary to keep the circula- 
tion sufficient to prevent the hair from falling out. 

Whether dandruff is a simple dry eczema of the skin, or is 
due to poor circulation, or is due to a germ, need not be here 
discussed, but the hair and scalp should be kept free from 
dandruff by brushing and shampooing. A simple soap, as 
ivory or castile, is frequently all that is necessary. More 
stimulating liquid soap, as green soap, may be used if deemed 
advisable, and if the head is greasy and the hair forms bundles 
from an extra amount of oil, a more drying treatment after 
the shampoo should be given, such as applications of bay rum 
or some other alcoholic preparation. 

Whether or not dandruff is due to a germ, many times anti- 
septic hair tonics represent the most successful treatment of the 
condition. The following is such an antiseptic wash: 



Mercuric chloride o 

Chloral 3 

Castor oil 5 

Alcohol 50 

Water up to 200 

Apply to the scalp, with a small sponge, every other night. 



02 Gm. 
Gm. 
mils 
mils 
mils 



The prevention of dandruff and falling of the hair means that 
the scalp must not become too dry or too oily. Drying is caused 
by too tight hats in men, and by curling irons in women, and 
disease of the scalp may occur from the use of dyes. Singeing 
does not prevent falling of the hair. 

All the dead hair should be combed out when the hair begins 
to fall after a serious illness (as it frequently does), and this is 
all the treatment that is needed. It is not necessary to shave 



warts 795 

the head; the hair is likely to come in as rapidly without shaving 
as it is with shaving. One of the causes of falling of the hair 
after severe illness is the ice cap, which is so frequently used on 
the head, and so many times without reason. 

When the hair falls, the general nutrition of the body should 
be studied. Many times there is chronic disability, or there is 
disturbance of some of the endocrine glands, frequently a subse- 
cretion of the thyroid. The diet and the condition of the skin 
should be studied. Sometimes the diet is deficient in some 
necessary element, perhaps calcium. An improvement of the 
general nutrition and of the circulation will often stop the loss 
of hair and cause its normal growth. 

Seborrhea and the falling of hair seems to have some rela- 
tionship to the sexual organs. Eunuchs do not become bald, 
and they are said not to have seborrhea. 

WARTS 

Warts may develop at any time, and occur singly or in groups, 
mostly on the hands, and mostly in children. It has been sug- 
gested that they may be due to a contagium. Warts may per- 
sistently recur, or, without any known cause, may suddenly and 
rapidly disappear within a few days. The administration of 
an extra amount of calcium has sometimes seemed to cause their 
disappearance. 

The local treatment is escharotic, and there is no treatment 
more satisfactory than cauterizing with the high frequency cur- 
rent, or with an electrocautery or a thermocautery. The older 
acid treatments are still much used, as a drop of glacial acetic acid 
or of nitric acid, or a drop of full strength official formaldehyde 
solution. If the formaldehyde solution is used, the treatment 
should be repeated, a drop at a time every three or four hours 
for a day or two. Less active treatments are salicylic acid 
preparations, and an efficient solution is salicylic acid 2 Gm. 
(30 grains) in collodion 30 mils (1 ounce). The wart should be 
touched with this collodion mixture two or three times a day, 
for several days. Many other local treatments have been sug- 
gested, but none is better than the above. 



79^ THE PRINCIPLES OF THERAPEUTICS 

SWEATING OF THE FEET AND A XILLJE— LOCALIZED 
HYPERIDROSIS 

Excessive perspiration of the axillae is very frequent, espe- 
cially among women, and sometimes the odor is very objection- 
able. Sweating of the feet is more frequent with men than with 
women, and sometimes the odor is simply disgusting. There 
can be no excuse for men and women making themselves ob- 
noxious if they are suffering from this disagreeable condition, as 
the disagreeableness to others can be prevented, but only by 
constant care on the part of the individual. Sometimes the 
curative treatment of these conditions is very successful; at 
other times all treatments are unsuccessful, and the patient's 
personal care of the condition must be persistent and continuous. 

From 2 to 5 percent, solutions of the official Liquor Formalde- 
hydi for bathing the axillae and for washing the feet often pre- 
vent the profuse secretion, and are absolutely successful in 
inhibiting the disagreeable odor. Various drying powders, 
combined with thin clothing, proper socks and proper shoes 
(rubber-soled shoes should not be used by persons whose feet 
perspire freely) may be more or less successful. A good drying 
powder is: 

Salicylic acid 2 Gm. 

Bismuth subnitrate 20 Gm. 

Starch 20 Gm. 

Or, 

Boric acid 10 Gm. 

Purified talc 100 Gm. 

Or equal parts of alum and talcum powder may be used. 

Alcoholic and tannic acid washes, and chromium trioxide and 
potassium permanganate solutions have all been used with more 
or less success. A few Roentgen ray treatments may be very 
successful. 

Stillian 1 has recommended a 25 per cent, solution of aluminum 
chloride to be swabbed on the sweating areas every second or 
third day, the solution being allowed to dry on the part. Three 
applications he finds sufficient, until there is a recurrence of the 
condition; in inveterate cases he would have the solution used 

1 Journal A. M. A., Dec. 30, 1016, p. 2015. 



OTITIS MEDIA 797 

once a week. Too frequent or too profuse use of this solution 
causes irritation of the skin. Aluminum hydroxide may be 
used as a dry dusting powder. 

INGROWING TOE-NAIL 

The first treatment of this condition is to see that the stock- 
ings or socks are large enough, and that the shoes are large 
enough not to cause the toes to be pressed together. The local 
treatment consists in frequent applications of peroxide of 
hydrogen to stop the infection, cauterizing exuberant granu- 
lations with a drop of liquified phenol, if such treatment is 
necessary, and then inserting hydroxide of aluminum powder 
between the nail and the inflamed toe. Cotton should be 
gently pressed underneath the corner of the nail to prevent its 
digging into the flesh. Sometimes the thickened edge of the 
nail should be thinned so that it will be more flexible. At 
times the condition is so serious as to require more radical 
surgical treatment. 

INFLAMMATION OF THE MIDDLE EAR— OTITIS MEDIA 

Inflammation of the middle ear is very common and occurs 
very frequently, following influenza and infections of the naso- 
pharynx. It often follows measles and scarlet fever, and is 
frequently due to mistaken treatment of the nose and naso- 
pharynx by improper nasal douching. Nasal douching is 
generally a mistake unless it is done by slowly pouring the 
solution into the nostril from a small vial or from a spoon, 
or by snuffing the fluid through the nostrils to the nasopharynx; 
but douching apparatus and the goose-neck nasal douche are 
menaces to the ears. The most frequent germs of infection 
occurring in the middle ear are the streptococcus and the 
pneumococcus. 

When pain occurs in an ear and does not quickly subside, or 
if after subsiding the hearing of the ear is impaired, an aurist 
should see the patient, unless the physician in charge is himself 
expert in diagnosing the condition of the ear drum. If possible, 
a drum should not be allowed to perforate from fluid or suppu- 
ration occurring in the middle ear. The drum should be incised 



798 THE PRINCIPLES OF THERAPEUTICS 

as soon as it bulges. The pain will immediately cease, and the 
danger of forcing infection into the mastoid will be minimized. 
Also, a clean cut incision in the drum will readily heal to make 
a perfect drum, while a perforated drum may never perfectly 
heal. 

Various solutions are used as ear drops to soothe the inflamed 
drum and to quiet the pain. Suggestions for simple solutions 
are as follows: 

Boric acid 1 Gm. 

Tincture of opium 10 mils 

Glycerin 20 mils 

Water up to 50 mils 

This should be warmed and a few drops allowed to run into the 
ear, and then a small pledget of cotton should be gently inserted 
into the external canal. 
Or, 

Boric acid 2 Gm. 

Glycerin 50 mils 

Water up to 100 mils 

This should be warmed and half a teaspoonful poured into the 
ear once in two or three hours, held there for a few minutes, then 
allowed to run out, and cotton placed in the canal as before. 
Or, 

Liquid phenol 1 mil 

Glycerin 20 mils 

Water up to 50 mils 

This should be warmed and several drops allowed to run into the 
ear every three or four hours, and then cotton placed in the 
canal. 

Also the following is often efficient: 

Cocaine hydrochloride o . 20 Gm. 

Epinephrine chloride o . 02 Gm. 

Boric acid o . 50 Gm. 

Glycerin 5 • mus 

Camphor water up to 25 . mils 

Warm and use as ear drops every three or four hours. 
These soothing measures should not be allowed to befog the 
careful investigation by the physician as to whether or not the 



LEUCORRHEA 799 

drum needs incision. The treatment after incision, and if 
there is actual suppuration, should be supervised, if not actu- 
ally carried out, by an ear specialist. 

LEUCORRHEA 

Leucorrhea is of very frequent occurrence, due many times 
to some systemic condition; debility, tire, over-standing, and 
poor circulation are often causes of vaginal discharge. It is 
not purposed to here discuss the local causes of leucorrhea. 
Necessary examinations should be made, and proper treatment 
should be given in each case; but in young girls before sub- 
jecting them to pelvic examinations, their general condition 
should be studied, and if found at fault, corrected. 

Some women take too frequent douches; others take them too 
infrequently, unless they take sitz baths. Long periods of vagi- 
nal douching are inadvisable. The simplest douch is one of 
boric acid or borax (i or 2 per cent, solution) with or without 
bicarbonate of sodium. There is no harm in a saturated solu- 
tion of boric acid, if there is much purulent discharge and much 
odor. Such a douching may be given once or twice a day, 
depending upon the conditions present. Douches of yeast solu- 
tions are valuable (one yeast cake dissolved in a pint of warm 
water) . 

If it is advisable to use a stronger astringent solution once 
a day or once in two or three days, the following is a useful 
formula : 

Zinc sulphate 5 Gm. 

Dried alum 10 Gm. 

Water 500 mils (1 pint) 

A stronger astringent solution is a }^ per cent, solution of 
copper sulphate. 

Weak glycerin or boroglycerin suppositories, or suppositories 
containing tannic acid or ichthyol are often of value in curing 
a leucorrhea. Of course if the vaginal discharge is caused by 
pelvic or uterine inflammation, the cause must be treated. 



PART XIII 
PRACTICAL ADVICE TO YOUNG PHYSICIANS 

SOME TRUTHS ABOUT DRUGS 

In spite of all the various physical, dietary, psychical and 
special treatments that may be needed for a given patient, pre- 
scriptions for drugs are frequently necessary to overcome 
abnormal conditions. A drug may be needed to stop pain, to pro- 
duce sleep, to increase elimination, to quiet nervous irritability, 
to inhibit or to stimulate the activity of some organ or gland, 
and to promote general nutrition. While many patients, both 
in acute and chronic conditions, need no drugs, there are but 
few diseases that do not require some aid from medication, 
although that medication may be of the simplest kind. If 
the patient requires no medicinal treatment he should not be 
given drugs, unless he is one of those who must take something 
for its mental effect, then some harmless mixture may be given. 

If it is necessary to write a prescription and to administer 
drugs, it is essential to know what drugs are useful and have 
activity, and what preparations of each drug are the most valu- 
able. Also, a drug should not be used that is not known to have 
some definite, safe activity. It is essential that a drug should 
not be prescribed or administered to an individual except by one 
who understands the condition of the patient and the action of 
the drug he prescribes. It is also self-evident that a patient 
should be individualized, and a mixture of drugs which may be 
well adapted to one individual is likely not to be at all appro- 
priate for, or advisable to administer to, another individual, 
although he may have the same disease. Consequently, mix- 
tures kept ready prepared, so-called stock mixtures, whether in 
drug stores, hospitals, or dispensaries, or as proprietary mixtures, 
do not represent good treatment for the individual sick. On 
the other hand, it may be advisable, as some of the Pharmaco- 
pceial preparations represent, to have in stock a definite, palata- 
ble preparation that offers so much of a given drug in each 

800 



ADVICE TO YOUNG PHYSICIANS 8oi 

five mils. The physician may prescribe such a preparation in 
the amount needed for the individual patient. 

To present this in another form, there is no use for a useless 
drug, even if that drug is officialized in the Pharmacopoeia. If 
there is no use for such drugs, there certainly is no use for their 
preparations, consequently nearly half of the drugs and prepara- 
tions of the Pharmacopoeia could be eliminated without medical 
loss. 

Also, multiple mixtures, as just stated, are inexcusable, and 
if such is granted to be a fact, most of the preparations of the 
National Formulary are unnecessary and superfluous. The 
same is true of very many proprietary mixtures, for which there 
is absolutely no excuse. A given useful drug may be presented 
in a very pleasant form by some proprietary firm, or some new 
synthetic drug may be offered. Such kind of pharmacal chem- 
istry is to be encouraged. Elegance of preparation and in- 
creased purity of a drug is the height of scientific pharmacy, 
and such work is necessary as an aid to the physician who pre- 
scribes the drug, and for the benefit of the patient who needs it. 

Nothing stated in the above should discourage a sensible 
association of drugs that act more or less in the same way. A 
combination of several laxative drugs, for instance, may be 
better than a large dose of one, and as the individual pharmacist 
cannot combine these as accurately or as elegantly as can a 
pharmaceutical firm that makes the tablets or pills by machin- 
ery, many thousands at a time, such prepared tablets or pills 
may be ordered. 

Given a useful drug, it would seem absurd to use any prepa- 
ration except the best one of that drug ; consequently, except in 
a few instances, many preparations of a drug are not neces- 
sary, and again the Pharmacopoeia grows smaller. 

Therefore, in the treatment of disease it should be the object 
of the physician not to give drugs unless they are needed; if a 
drug is needed, to give the best drug that meets the indication 
by its physiologic activity, and to prescribe that drug in the 
most active preparation, in the simplest manner possible. In 
other words, there must be simplicity of treatment and simplic- 
ity in prescriptions. 

51 



8o2 THE PRINCIPLES OF THERAPEUTICS 

The medical student at the end of his third year is many 
times better prepared to prescribe useful drugs in a useful way 
than is the student at the end of his fourth year, or is the 
physician who has spent one or two years in a hospital. The 
fourth year student receives clinical instruction both in the 
hospital and in the dispensary, and hears mixtures ordered by 
number, or by some fancy name, without knowing what the 
solution, pill, or powder contains. This same indefinite medica- 
tion goes through his hospital internship, and except in certain 
particular conditions such as heart failure or when some new 
drug is studied, he has little idea of the exact dosage that the 
patient has received of any particular one drug. He therefore 
begins active practice with little knowledge of scientific or 
rational medication. It is also regrettable that the hospitals 
will not adopt the metric system in prescription writing, 
although they constantly use percentage solutions in the 
laboratories and in the surgical clinics. 

Education and scientific knowledge does not save a man or a 
woman from a belief in the mysterious, and the physician is no 
exception. While the layman may have faith in talismans and 
amulets, horse chestnuts, iron rings, and in some particular 
patented medicine, the physician, unless he is particularly well 
balanced and particularly prone to self-inspection and to care- 
ful study of his patients, will often acquire a belief in some 
proprietary mixture, or even in some mixture of his own, and 
will report unusual and continuous favorable results from such 
medication. If each physician will take a pencil and draw a 
line through the inactive ingredients of some mixture, he will 
find that there is probably one single drug that is causing 
success in his treatment, and the mystery will disappear. Or, 
he will find that there is nothing in the prescription at all, that 
it is really his own enthusiasm and his general care of the 
patient that cause the improvement. 

No man who has taken a course in a pharmacologic labora- 
tory, or who has carefully watched the action of active drugs 
on patients who needed such active help, can be an agnostic as 
to the value of drugs. Besides the drugs that are demonstrated 
to be active in the pharmacologic laboratories, the practising 



ADVICE TO YOUNG PHYSICIANS 803 

physician can learn which of the newer drugs and preparations 

are of value by reference to the annual edition of "New and 

Non-official Remedies," issued by The American Medical 

Association. However, it is true that the number of useful 

drugs is not many, and it may be interesting to note that in 

1 91 6 "The Medical Review of Reviews" solicited the opinion 

of noted therapists as to which were the five most useful drugs. 

It was understood that the anesthetics and antitoxins were 

excluded from consideration in this vote. One hundred and 

seven answers were received by the medical journal, and the 

five drugs voted (almost unanimously) as most useful were 

opium, mercury, cinchona, digitalis, and iodine, with arsenic 

(as arsphenamine) and salicylates as the sixth and seventh 

choice. 

A FEW" DRUG APHORISMS 

Alum should not be used as a mouth wash or as a gargle. 

Bismuth subcarbonate is preferable to bismuth subnitrate, 
as the latter under certain conditions can cause poisoning. 

There is no excuse or justification for ever using nitrate 
of silver, potassium chlorate, or zinc preparations internally. 
An exception is when zinc sulphate is used as an emetic. 

If tannic acid is desired for action in the intestines, one 
of its combinations, that is not irritant to the stomach, should 
be used. 

As a bitter tonic, administered in solution before a meal, 
none is more efficient than the tincture of gentian, or the 
tincture of cinchona, in teaspoonful doses, or the tincture of nux 
vomica, in one drop doses. 

The only preparations of iron needed are the reduced iron, 
the carbonate of iron pill, and the saccharated oxide of iron. 
Inorganic irons are of no more physiologic value than are these. 

Dilute hydrochloric acid is, in the majority of cases, the only 
digestant a patient requires. Pepsin and diastase are rarely 
needed, and pancreatin is most valuable as a pre-digester. 

If lime is needed and milk is not advisable, calcium glycero- 
phosphate is one of the best preparations. 

One or two salts of quinine are sufficient. Cinchonidia and 
cinchonina are not needed. The tannate of quinine is of little 
value. 



804 THE PRINCIPLES OF THERAPEUTICS 

A large number of the so-called vegetable cathartics are not 
needed, and the multiple ingredients of the compound cathartic 
pill should render it only of historical interest. Pre-operative 
severe purging is now inexcusable. Such treatment causes gas 
distention, more or less congestion, post-operative pains, and 
more or less paresis of the bowels and promotes shock. 

No other drug will inhibit profuse perspiration as efficiently 
as does atropine. 

Water, caffeine in some form, and digitalis are efficient 
diuretics. The many other so-called diuretics are not needed. 

To render the urine alkaline, no drug is better than potas- 
sium or sodium citrate. There is no necessity for, or wonderful 
action from, the "ABC mixture." 

As genitourinary antiseptics hexamethylenamine, phenyl 
salicylate (salol) and other salicylic acid preparations are 
efficient. 

As a stimulant to the genitourinary tract, and also as a mild 
antiseptic, nothing is better than the oil of santal. 

As emmenagogues, iron, thyroid extract, and at times corpus 
luteum are the most efficient. The many mixtures lauded for 
dysmenorrhea and disturbances of the menstrual function are of 
value only on account of their alcohol content. If alcohol is 
advisable, it should be ordered wittingly, and not in some pro- 
prietary mixture. 

As expectorants nothing has been shown to be better than 
ammonium chloride, ipecac, and iodides. 

To diminish the secretion of the air passages, no drugs are 
more valuable than atropine, terpin hydrate, and, if needed, 
codeine. All of the other so-called expectorants are unneces- 
sary and are often harmful to the stomach. 

Every treatment of asthma which is efficient contains an 
atropine in some form, an alkaloid or preparation of opium, or a 
nitrite. Bromides and chloral may at times be of value, and 
caffeine and suprarenal are often efficient, but all of the many 
preparations of belladonna, stramonium, and hyoscyamus are 
superfluous. All of the proprietary and mysterious prepara- 
tions for asthma contain more or less of these drugs. 

The newer coal-tar products or synthetics of the antipyretic 



ADVICE TO YOUNG PHYSICIANS 805 

and analgesic class have not been shown to be improvements on 
the original acetanilid, antipyrine and acetphenetidin. 

Chloral is still the most efficient hypnotic, and barbital- 
sodium (veronal-sodium) is thus far the best synthetic drug for 
this purpose. 

Sodium bromide and potassium bromide are the only bromide 
salts that are needed. All others are absolutely superfluous. 

In most instances sodium iodide is better than potassium 
iodide, and other iodide preparations are not improvements on 
these two drugs. A very small dose of sodium iodide is as 
efficient as a larger dose of some preparation which contains but 
little iodine, and generally an iodide "without its sting" is a 
preparation that contains but little iodine. 

Salicylic acid preparations that cause no disturbance of the 
patient act thus pleasantly because they do not offer much 
salicylic acid. If the action of salicylic acid is needed, it must 
be pushed to mild salicylism. 

Acetyl salicylic acid (aspirin) will reduce temperature and 

stop pain, and may relieve some symptoms of rheumatism, but 

the drug is too depressant to use in acute inflammatory 

rheumatism. 

DRUG FALLACIES 

Sweet spirits of niter as a diuretic is a joke. 

A solvent action of lithium is unproved, and any benefit 
from waters containing lithium is due to the amount of water 
drunk. 

Hypophosphites as such are worthless, and practically no 
hypophosphite solution is offered by any proprietary firm unless 
it contains such drugs as quinine, iron, strychnine, etc. There 
is no use for hypophosphites. 

There is no tonic, so-called alterative, or any other kind of 
action from sarsaparilla. 

Valerian is of no benefit in hysteria except by its smell, 
unless it is put up in an alcoholic preparation and the patient 
is alcoholized. 

The old lead and opium wash is no longer a muddy necessity. 
It is too bad to so misuse opium! 

The "rhinitis" tablet to stop colds, if analyzed as to its 



806 THE PRINCIPLES OF THERAPEUTICS 

ingredients, resolves itself into nothing but the action of its 
atropine, and a tablet representing }i 00 of a grain of atropine 
sulphate will act as satisfactorily as any rhinitis tablet. 

Basham's mixture (Liquor Ferri et Ammonii Acetalis) which 
contains very many ingredients, with aromatics, supposed by all 
hospitals and a large number of physicians to be of great value 
in Bright's disease, is an old combination that has no special 
value except in the mind of the one prescribing it. There is no 
question that many patients who have Bright's disease need iron 
in some simple form, but there is no physiologic or therapeutic 
necessity for administering the mixture named after Doctor 
Basham. 

Many of the mixtures still retained in the Pharmacopoeia, 
notably the compound cathartic pill which contains eight 
ingredients, the compound mixture of glycyrrhiza (Brown 
Mixture) which contains six ingredients, the syrup of hypophos- 
phites which contains three hypophosphites and hypophos- 
phorous acid, the compound syrup of sarsaparilla which contains 
seven ingredients, the compound syrup of squill (Hives' 
Syrup) which contains three ingredients, are all more or less 
respectable antiques. 

The compound tincture of lavender containing five or six 
spices is a pleasant alcoholic preparation that may be used 
judiciously in the present dearth of cocktails. 

THERMOMETRIC EQUIVALENTS 

To convert degrees Centigrade to degrees Fahrenheit, 
multiply by 9, divide by 5, and add 32 to the quotient. To 
convert degrees Fahrenheit to degrees Centigrade, subtract 32, 
multiply by 5, and divide by 9. A few commonly used equiva- 
lents are as follows: 

C. F. 

o = +32 Freezing point of water. 
+ 20 = -f- 68 Good room temperature. 
+ 37 = + 98'- 6 About normal body temperature. 
+ 60 = +140 Pasteurizing temperature. 
+ 100 = +212 Boiling point of water. 



ADVICE TO YOUNG PHYSICIANS 807 

CLINICAL HISTORIES 

If a patient is seriously ill, the trained nurse will keep records 
of the case after the physician has taken the history of the 
patient's immediate past and the story of the invasion of the 
present disease. In hospitals this is done by the medical 
interne, and elaborated by the attendant. 

Unfortunately, many physicians are very careless in not 
taking and carefully following histories of the patients who 
come to their office for treatment. For medical success good 
history taking is absolutely essential. It is not necessary to 
ascertain the family tendencies, or whether the individual had 
mumps as a child, if he comes to the office for a sore throat or a 
tonsillitis. It is, however, absolutely essential to investigate 
the whole history of the case, if the patient comes with some 
chronic systemic condition. 

It is not necessary for each physician to have the same plan 
or arrangement for his history taking, provided he follows out 
constantly his own method; it is unimportant whether he gets 
the general history of the patient's previous condition first, or 
the history of the present condition first. A working plan is to 
obtain the name, age, sex, condition (married or single), occupa- 
tion, complaint in all its details, duration, history of previous 
diseases, and a brief family history. 

Then begins the examination of the patient. First, the verbal 
examination, which should be more or less brief, or more or less 
in careful detail, depending upon the complaint of the patient: 
(1) a detail of the exact occupation and life; (2) the diet, 
especially the amount of tea and coffee and meat taken, and 
whether there is a craving for any particular article of food, or 
whether much sugar is eaten; (3) as to appetite, flatulence, 
pyrosis, nausea, vomiting, abdominal pain, and the activity of 
the bowels; (4) the ability to sleep, and whether or not the 
patient rises to urinate, and the number of times; (5) the 
ordinary daily frequency of urination, and any disturbance of 
that function evident to the patient; (6) the occurrence of pain, 
not previously mentioned by the patient, as headache, or joint or 
muscle pains ; (7) whether or not there is palpitation, dyspnea on 
exertion, or bleeding from any part; and (8) whether or not there 



808 THE PRINCIPLES OF THERAPEUTICS 

is cough, and the character of the cough and expectoration. If 
there are headaches, the character of the headache should be 
ascertained, and a careful study of the relation of the use of the 
eyes to the headaches should be made. 

In women, abnormalities of the menstrual function should be 
noted, and the number of children born and the number of mis- 
carriages, if any, should be recorded. 

Next, there should be a discussion of the tobacco habit, and 
of an alcohol or any drug habit; and the frequency of taking 
drugs of any kind should be ascertained. 

The second part of the examination is physical, and should 
begin with inspection as to the color and texture of the skin ; as 
to the general nutrition; as to abnormalities. Next there should 
be inspection of the tongue, throat, tonsils, teeth, and gums; the 
ordinary reflexes should be tested; and the pulse and tempera- 
ture taken. The examination proceeds with a careful study of 
the heart with the patient sitting, standing, and lying down ; and 
the blood-pressure is taken. Examination of the lungs is by 
inspection, percussion, and auscultation, and by any other 
method deemed necessary. A careful examination of the abdo- 
men with the patient both standing, and lying down must be 
made, and finally the urine must be tested. The above ex- 
aminations are essential in every case that is to be properly 
treated, unless the condition is an acute, simple, self-evident 
disease. 

Special examinations need not be outlined. One patient 
requires an examination of the twenty-four hour urine, another 
a kidney test, another a differential blood count, another an 
examination of the sputum, another requires a culture made 
from some excretion, another a careful eye examination, another 
an ear examination, another an x-ray picture, and another a 
pelvic examination. Pelvic examinations should be much more 
frequently made, both in males and females. 

The treatment is then outlined and carefully recorded, and 
the history card filed, ready for use on subsequent visits. A 
criticism of previous decisions and of the treatment given should 
follow on the card, at each date that the patient is again seen, 
and many times a careful review of the whole history just before 
the patient returns will enable the physician to give him 



ADVICE TO YOUNG PHYSICIANS 



809 



the best advice possible. Self criticism by the physician, and 
the consideration of whether or not some other technical 
examination should not be made, means the best care of a 
patient which the physician can give. 

Suggestive for the treatment and management of a patient 
is the following therapeutic chart: 




8lO THE PRINCIPLES OF THERAPEUTICS 

THE HYPODERMIC CASE 

The hypodermic case should contain tablets of: 

Apomorphine hydrochloride each }{ grain. 
Strychnine sulphate each %o grain. 
Morphine sulphate each 3^ grain. 
Atropine sulphate each Jlso grain. 
Scopolamine hydrochloride each J^ 00 grain. 
Nitroglycerin each Jfoo grain. 
Strophanthin each 3<5oo grain. 

THE POCKET MEDICINE CASE 

The pocket medicine case should contain for dispensing (in 
small numbers) the following tablets: 

Morphine sulphate % grain 

Strychnine sulphate 3^0 grain 

Nitroglycerin 3^ 00 grain 

Atropine sulphate }ioo grain 

Quinine sulphate }£ grain 

Acetanilid (i grain) with sodium bicarbonate (3 grains). 

Sodium bromide 5 grains 

Calomel (% grain) with sodium bicarbonate (1 grain). 
Compound aloin, a good formula for which is: 

Aloin o . 02 Gm. (% grain) 

Powdered ipecac o . 03 Gm. (3^ grain) 

Strychnine sulphate 0.0015 Gm. (3^o grain) 

Extract of belladonna o. 006 Gm. (3-fo grain) 

The doses of some of the above tablets are small, but more 
than one tablet may be given at a time, if needed. 

The small dose of atropine allows a tablet to be given every 
one or two hours, for a time, for colds. 

The quinine tablet is for use as a placebo, when some treat- 
ment is necessary though medication is not needed. 

THE ALWAYS-READY HANDBAG 

Preparedness in every respect is essential to render any 
service, and is an absolute necessity for the physician to 
render service in emergencies. Preparedness may mean saving 
of life, and always means saving of valuable time, both for the 
patient and for the physician; 



ADVICE TO YOUNG PHYSICIANS 8ll 

The physician's handbag should contain not only everything 
needed to meet an emergency, but many things that are needful 
in making a diagnosis. It should not be necessary for the 
physician to make another visit in order to take a throat culture; 
to take a blood smear for a malarial fever or typhoid test; to 
take blood for a blood count; to take blood for a Wasserman 11 
test; to do venesection; to do spinal puncture; or even to give 
a transfusion of physiologic saline solution. The small equip- 
ment necessary to do these things should be in the handbag. 

The bag should also contain male and female catheters, 
sterile lubricant oil, and a small test case for urine. It should 
also contain a pocket instrument case, gauze bandages, adhesive 
tape, bichloride of mercury tablets, tincture of iodine, a small 
can of ether, a bottle of chloroform and a chloroform inhaler, 
and cocaine and novocaine tablets. It should also contain a 
stomach tube complete with funnel, tongue depressors, a piece 
of solid rubber for placing between the teeth to keep the jaws 
apart, copper sulphate powders each containing 0.50 Gm., and 
powders containing zinc sulphate 1 Gm. and powdered ipecac 
2 Gm. for use as emetics. As milder emetics a small can of 
mustard and a bottle of syrup of ipecac for young children may 
be carried. A small bottle of tannic acid and a brief list of 
poisons and their antidotes completes this equipment. 

The bag should also contain the following preparations for 
hypodermic administration: Caffeine sodio-benzoate tablets, 
each 3 grains; ampules of ergot; ampules of strophanthin (K20 
grain) ; ampules of post-pituitary solution (1-10,000) ; ampules of 
epinephrine (1-10,000) ; ampules of camphor in oil; and ampules 
of digitalis. 

It is now possible to obtain individual sterile hypodermic 
units (each consisting of a needle and a collapsible tube 
containing the medicament), the Greeley patent, of most drugs 
used hypodermatically. Several of these containing such drugs 
as morphine, strychnine, atropine, and apomorphine may well 
be carried in the bag. - '■ ' ^ : * ' 

The bag is made complete with a small alcohol lamp, contain- 
ing solidified alcohol, and a small cup or spoon for sterilizing 
water; ■ 



Si 2 THE PRINCIPLES OF THEBAPEUTICS 

DRUGS FOR OFFICE DISPENSING 

There are some drugs that it is advisable for the physician 
to have in his office for personal dispensing. In a city these 
drugs need be but few, but where the physician is practising in 
the country it may be necessary to have many more than the 
list suggested. The tablets that it is wise to have on hand are: 
arsenic Jio grain (0.002 Gm.) ; protiodide of mercury J4 grain 
and H grain (0.015 and 0.03 Gm.) ; and a supply of the drugs that 
are suggested above for the pocket case. It is also advisable to 
personally dispense drugs that are being used for careful thera- 
peutic observation, not mixtures. It is not good form to dis- 
pense mixtures or even original packages of simple preparations 
left at the office by agents of pharmaceutical firms. Such 
should be examined and utilized as deemed best, if found 
satisfactory, or discarded, if found to be secret or unnecessary 
mixtures. 

The physician should have at hand, for ready reference, lists 
of the antitoxins, the antiserums, the vaccines, and useful rectal 
and vaginal suppositories. 

LIFE EXTENSION 

Statistics show: 

That about 1,500,000 Americans are constantly ill with pre- 
ventable disease. 

That we have about 350,000 deaths annually from tubercu- 
losis, typhoid fever, and other germ diseases. 

That there are about 75,000 deaths annually from cancer, 
which is on the increase. 

That there is a continued increase in the death-rate from 
cardiovascular-renal disease. 

That mouth infection in one form or another is at the 
present day a menace to the health of the nation. 

That accidental deaths are progressively increasing, and have 
nearly reached 90,000 annually. 

That suicidal deaths are on the increase. 

That nearly 75 per cent, of school children are suffering from 



LIFE EXTENSION 813 

physical or mental defect or impairment, or some condition 
prejudicial to health. 

That the use of cigarettes has doubled in the last five 
years. 

Insurance statistics, insurance examinations, examinations 
and re-examinations of enlisted men and of students, and the 
promoters of life extension methods, have compelled the medical 
profession to note, and the laity to begin to understand that 
periodic physical examinations are life-saving. It needs no 
discussion here to emphasize the importance of repeated exami- 
nations of growing children. 

The regular, perhaps once a year, examination of individuals 
supposed to be well may be made very complete with multiple 
laboratory details, but the greater refinements of these examina- 
tions are hardly necessary when the individual shows no symp- 
toms of disease. In early life the height and weight, the growth, 
the anatomical relation of one part of the body to another, and 
the range from perfection to various divergencies to the point 
of imperfection should be noted; station, posture^ walking, eye- 
sight, hearing, development of teeth, glandular conditions, etc., 
etc., should all be noted, and, when abnormal, corrected, if 
possible. 

Later examinations include the condition of the heart, blood- 
vessels, blood-pressure, urine, blood counts if necessary, the 
condition of the lungs, the condition of the digestive system, 
the general nutrition, and the condition and health of the skin. 
More rigid examinations include blood counts, Wassermann 
tests, reflex reactions of the nervous system, kidney tests of 
efficiency, twenty-four hour urine examinations, tests for diges- 
tive ability, tests of the feces on known diets, etc., tests for sugar 
tolerance, and roentgenograms of gastrointestinal functions and 
efficiency, various bacteriologic tests of different secretions, and 
tuberculin tests, all depending upon the thoroughness with 
which it is necessary to examine the individual patient. 

With all these examinations a most important one should not 
be forgotten, namely radiographs of all the teeth and of the 
sinuses of the face and nose. If necessary, more elaborate 
tests of the blood may be made, as for sugar content, for urea 



8 14 THE PRINCIPLES OF THERAPEUTICS 

and non-protein nitrogen content, for hydrogen-ion concentra- 
tion of the blood, and tests of the alveolar air, and tests for 
acidosis. If deemed advisable blood cultures should be made. 
At the present time an individual may go to an institution 
that has the facilities for complete physiologic and metabolic 
tests, and it may be possible by these methods to diagnose the 
cause of an obscure condition. 



PART XIV 

MEDICAL LAWS AND DEPARTMENTS OF HEALTH 

THE HARRISON NARCOTIC LAW 

The law requires every practising physician to pay to the 
collector of internal revenue of his district an annual fee of 
three dollars and to receive a license and a registry number, in 
order for him to legally prescribe, or dispense, or have in his 
possession opium or any of its alkaloids, heroin, or cocaine. 
If he requires for office use or for official dispensing any of 
these drugs, he must make out a requisition in duplicate, on a 
blank furnished by the internal revenue office. One copy he 
must keep; the other he gives to a pharmacal firm, which will 
furnish him the drug or drugs. 

If the physician writes a prescription containing any of the 
narcotic drugs named in this Act, except in minute quantities, 
he must write on a prescription blank that carries his address 
and registry number, and must date and sign the same, and 
must also write the name and address of the patient for whom 
the prescription is intended. The druggist must retain this 
prescription, and it cannot be repeated. 

If a narcotic drug named in the Act, is given the patient from 

the physician's own supply, a record must be kept, stating the 

date, to whom given, and the amount given. This record 

must be kept on file for inspection for at least two years. 

There are severe penalties for infringement of any of these 

regulations. 

THE PROHIBITION LAW 

The following rules and regulations are copied from a 
pamphlet issued from the Treasury Department by the Federal 
Prohibition Commissioner in the edition of February ist, 1920: 

Every physician must obtain a permit for him to legally 
have for office or emergency use alcohol in any form. With 
this permit he is entitled to no more than six quarts of liquor 
of any description during a calendar year. For a physician to 

815 



8l6 THE PRINCIPLES OF THERAPEUTICS 

legally order alcohol in any form for patients he must obtain a 
permit. "No prescription must be issued for a greater quantity 
of intoxicating liquor than is necessary for use as a medicine 
by the person for whom prescribed, and in no case may spiritous 
liquor in excess of one pint within any period of ten days be 
prescribed for the same person by one or more physicians." 

Special blanks must be obtained with printed stubs attached 
for duplicate prescriptions. These blanks, bearing the number 
of the permit, are also numbered serially. The prescription 
must be made out in duplicate, giving date, full name of patient, 
his street and number, city, state, ailment for which prescribed, 
kind and quantity of liquor ordered, directions for administra- 
tion, and be signed with the full name of the physician, his 
street and number, city and state. The physician must also 
write, in his own handwriting, the name of the pharmacist who 
is to fill the prescription. A prescription must not be filled 
but once. Also "every physician who prescribes intoxicating 
liquor is required to keep a record on book Form 1402 to be 
procured by him from the Director. The physician must keep 
a record alphabetically arranged for every prescription for 
intoxicating liquor issued by him, showing the date of the 
prescription, the amount and kind of liquor prescribed, the 
name of the patient to whom issued, the purpose or ailment 
for which prescribed, and the directions for use thereof, includ- 
ing the amount and frequency of the dose." 

The following Pharmacopceial and National Formulary 
preparations "will be regarded as intoxicating liquor, and may 
not be sold, purchased, bartered, transported, imported, 
exported, delivered, furnished, possessed, or used except as 
specifically authorized in these regulations:" 

Blackberry Cordial Compound Spirit of Juniper 

Aromatic Elixir Compound Spirit of Myrcia 

Elixir of Anise Bitter Tincture 

Red Aromatic Elixir Aromatic Tincture 

Elixir of Bitter Orange Tincture of Caramel 

Compound Elixir of Cardamom Compound Tincture of Cardamon 

Elixir of Licorice Compound Tincture of Lavender 

Aromatic Elixir of Glycyrrhiza Compound Wine of Orange 

Compound Elixir of Taraxacum Wine of Wild Cherry 



MEDICAL LAWS 817 

A patient may obtain alcohol for external use in quantities 
not exceeding one pint, provided that the container bears the 
label, "a poison." Alcohol is legally made poisonous by the 
addition of one of the following drugs or preparations: 

Bichloride of Mercury 

Formaldehyde 

Carbolic Acid and Tannic Acid 

Compound Solution of Cresol 

" Physicians may not prescribe liquor for their own personal 
use, and pharmacists should refuse to fill any such prescription 
presented to them." 

REPORTABLE DISEASES 

All communicable diseases, as soon as diagnosed, must be 
reported to the local board of healthy or to the health officer 
of the district. While the list of reportable diseases and 
the rules for the prevention of the infection of others vary 
in the different states and cities, the following lists are complete, 
and represent those diseases that should be reported: All of 
the so-called infectious diseases of children, such as chicken pox, 
diphtheria, German measles, measles, mumps, scarlet fever, 
and whooping cough. Such special infections as cerebrospinal 
meningitis, f avus, infectious conjunctivitis (pink eye) , ophthal- 
mia neonatorum, poliomyelitis, and trachoma. The general 
infections of dysentery (amebic and bacillary), gonorrhea, 
influenza, malaria, pneumonia, septic sore throat, small pox, 
syphilis, tetanus, tuberculosis (all forms), and typhoid , paraty- 
phoid and typhus fever. Also the unusual conditions of anthrax, 
Asiatic cholera, glanders, leprosy, pellagra, plague, rabies, yellow 
fever, and sleeping sickness. 

Many communities do not consider it necessary to report 
chicken pox, infectious conjunctivitis (pink eye), influenza, 
malaria, mumps, and pneumonia, but certainly with the recent 
experience with influenza and pneumonia, at least these 
diseases should be reported. 

52 



8l8 THE PRINCIPLES OF THERAPEUTICS 

STATE DEPARTMENT OF HEALTH 

A National Department of Health located in Washington 
cannot be many years longer delayed. There are already many 
public health services, but except in sudden serious epidemics 
the Central Government does not interfere with the Depart- 
ments of Health of the several states. In each state the 
Department of Health stands between the individual and 
disease, and aims to promote the health of communities. 

Categorically the Department of Health of each state should 
promote health laws and sanitation in all forms; should teach, by 
bulletins, pamphlets, exhibits, lectures, and films, the truth 
concerning the prevention of disease; should ascertain and 
guarantee the purity of water and milk supplies, and of all the 
food products developed and made ready, for sale or for export, 
within the state; should investigate any food suspected of being 
adulterated or polluted that comes into the state ; should regu- 
late the disposal of sewage; should investigate all nuisances; 
should furnish when necessary free vaccines and antitoxins; 
should offer laboratory facilities for scientifically diagnosing 
infections; should assist local health boards, or take full charge, 
in the suppression of epidemics; should supervise medical 
practice in all its branches; and should, through its department 
of vital statistics, keep records of births, parentage, marriages, 
deaths, and of all reportable diseases. 



PART XV 
MEDICAL ETHICS 

It is essential that a graduate in medicine should know 
some of the ethics of his profession. Toward that end a copy 
of the " Principles of Medical Ethics of the American Medical 
Association" is presented by special permission. 

Copyright, 1914, by the American Medical Association 

CHAPTER I 
THE DUTIES OF PHYSICIANS TO THEIR PATIENTS 

The Physician's Responsibility 

Section 1. — A profession has for its prime object the service 
it can render to humanity; reward or financial gain should 
be a subordinate consideration. The practice of medicine 
is a profession. In choosing this profession an individual 
assumes an obligation to conduct himself in accord with its 
ideals. 

Patience, Delicacy and Secrecy 

Section 2. — Patience and delicacy should characterize all 
the acts of a physician. The confidences concerning individual 
or domestic life entrusted by a patient to a physician and the 
defects of disposition or flaws of character observed in patients 
during medical attendance should be held as a trust and should 
never be revealed except when imperatively required by the laws 
of the state. There are occasions, however, when a physician 
must determine whether or not his duty to society requires him 
to take definite action to protect a healthy individual from 
becoming infected, because the physician has knowledge, 
obtained through the confidences entrusted to him as a phy- 
sician, of a communicable disease to which the healthy indi- 
vidual is about to be exposed. In such a case, the physician 



820 THE PRINCIPLES OF THERAPEUTICS 

should act as he would desire another to act toward one of his 
own family under like circumstances. Before he determines 
his course, the physician should know the civil law of his 
commonwealth concerning privileged communications. 

Prognosis 

Section 3. — A physician should give timely notice of danger- 
ous manifestations of the disease to the friends of the patient. 
He should neither exaggerate nor minimize the gravity of the 
patient's condition. He should assure himself that the patient 
or his friends have such knowledge of the patient's condition as 
will serve the best interests of the patient and the family. 

Patients must not be Neglected 

Section 4. — A physician is free to choose whom he will serve. 
He should, however, always respond to any request for his assis- 
tance in an emergency or whenever temperate public opinion 
expects the service. Once having undertaken a case, a phy- 
sician should not abandon or neglect the patient because the 
disease is deemed incurable; nor should he withdraw from the 
case for any reason until a sufficient notice of a desire to be 
released has been given the patient or his friends to make it 
possible for them to secure another medical attendant. 

CHAPTER II 

THE DUTIES OF PHYSICIANS TO EACH OTHER AND 
TO THE PROFESSION AT LARGE 

Article I. — Duties to the Profession 

Uphold Honor of Profession 

Section 1. — The obligation assumed on entering the profession 
requires the physician to comport himself as a gentleman and 
demands that he use every honorable means to uphold the 
dignity and honor of his vocation, to exalt its standards and to 
extend its sphere of usefulness. A physician should not base 
his practice on an exclusive dogma or sectarian system, for 



MEDICAL ETHICS 82 1 

"sects are implacable despots; to accept their thraldom is 
to take away all liberty from one's action and thought." 
(Nicon. father of Galen.) 

Duties oe Medical Societies 

Section 2. — In order that the dignity and honor of the medical 
profession may be upheld, its standards exalted, its sphere 
of usefulness extended, and the advancement of medical 
science promoted, a physician should associate himself with 
medical societies and contribute his time, energy and means 
in order that these societies may represent the ideals of the 
profession. 

Deportment 

Section 3. — A physician should be "an upright man, instruct- 
ed in the art of healing." Consequently, he must keep 
himself pure in character and conform to a high standard of 
morals, and must be diligent and conscientious in his studies. 
He should also be modest, sober, patient, prompt to do his 
whole duty without anxiety; pious without going so far as 
superstition, conducting himself with propriety in his profession 
and in all the actions of his life. " (Hippocrates.) 

Advertising 

Section 4. — Solicitation of patients by circulars or advertise- 
ments, or by personal communications or interviews, not 
warranted by personal relations, is unprofessional. It is 
equally unprofessional to procure patients by indirection 
through solicitors or agents of any kind, or by indirect advertise- 
ment, or by furnishing or inspiring newspaper or magazine 
comments concerning cases in which the physician has been or 
is concerned. All other like self-laudations defy the traditions 
and lower the tone of any profession and so are intolerable. 
The most worthy and effective advertisement possible, even 
for a young physician, and especially with his brother physi- 
cians, is the establishment of a well merited reputation for 
professional ability and fidelity. This cannot be forced, but 
must be the outcome of character and conduct. The publica- 



82 2 THE PRINCIPLES OF THERAPEUTICS 

tion or circulation of ordinary simple business cards, being a 
matter of personal taste or local custom, and sometimes of 
convenience, is not per se improper. As implied, it is un- 
professional to disregard local customs and offend recognized 
ideals in publishing or circulating such cards. 

It is unprofessional to promise radical cures; to boast of cures 
and secret methods of treatment or remedies; to exhibit certifi- 
cates of skill or of success in the treatment of disease; or to 
employ any methods to gain the attention of the public for the 
purpose of obtaining patients. 

Patents and Perquisites 

Section 5. — It is unprofessional to receive remuneration 
from patents for surgical instruments or medicines; to accept 
rebates on prescriptions or surgical appliances, or perquisites 
from attendants who aid in the care of patients. 

Medical Laws — Secret Remedies 

Section 6. — It is unprofessional for a physician to assist 
unqualified persons to evade legal restrictions governing the 
practice of medicine; it is equally unethical to prescribe or 
dispense secret medicines or other secret remedial agents, or 
manufacture or promote their use in any way. 

Safeguarding the Profession 

Section 7. — Physicians should expose without fear or favor, 
before the proper medical or legal tribunals, corrupt or dishonest 
conduct of members of the profession. Every physician 
should aid in safeguarding the profession against the admission 
to its ranks of those who are unfit or unqualified because 
deficient either in moral character or education. 

Article II. — Professional Services of Physicians to 

Each Other 

Physicians Dependent on Each Other 

Section 1. — Experience teaches that it is unwise for a phy- 
sician to treat members of his own family or himself. Conse- 



MEDICAL ETHICS 823 

quently, a physician should always cheerfully and gratuitously 
respond with his professional services to the call of any phy- 
sician practising in his vicinity, or of the immediate family 
dependents of physicians. 

Compensation for Expenses 

Section 2. — When a physician from a distance is called on to 
advise another physician or one of his family dependents, and 
the physician to whom the service is rendered is in easy financial 
circumstances, a compensation that will at least meet the 
travelling expenses of the visiting physician should be proffered. 
When such a service requires an absence from the accustomed 
field of professional work of the visitor that might reasonably 
be expected to entail a pecuniary loss, such loss should, in 
part at least, be provided for in the compensation offered. 

One Physician to Take Charge 

Section 3. — When a physician or a member of his dependent 
family is seriously ill, he or his family should select a physi- 
cian from among his neighboring colleagues to take charge of the 
case. Other physicians may be associated in the care of the 
patient as consultants. 

Article III. — Duties of Physician in Consultations 
Consultations Should be Required 

Section 1. — In serious illness, especially in doubtful or 
difficult conditions, the physician should request consultations. 

Consultation for Patient's Benefit 

Section 2. — In every consultation, the benefit to be derived 
by the patient is of first importance. All the physicians 
interested in the case should be frank and candid with the 
patient and his family. There never is occasion for insincerity, 
rivalry or envy and these should never be permitted between 
consultants. 



824 the principles of therapeutics 

Punctuality 

Section 3. — It is the duty of a physician, particularly in the 
instance of a consultation, to be punctual in attendance. When, 
however, the consultant or the physician in charge is unavoid- 
ably delayed, the one who first arrives should wait for the other 
for a reasonable time, after which the consultation should be 
considered postponed. When the consultant has come from a 
distance, or when for any reason it will be difficult to meet the 
physician in charge at another time, or if the case is urgent, or 
if it be the desire of the patient, he may examine the patient and 
mail his written opinion, or see that it is delivered under seal, 
to the physician in charge. Under these conditions, the con- 
sultant's conduct must be especially tactful; he must remember 
that he is framing an opinion without the aid of the physician 
who has observed the course of the disease. 

Patient Referred to Specialist 

Section 4. — When a patient is sent to one specially skilled 
in the care of the condition from which he is thought to be suffer- 
ing, and for any reason it is impracticable for the physician in 
charge of the case to accompany the patient, the physician in 
charge should send to the consultant by mail, or in the care of 
the patient under seal, a history of the case, together with the 
physician's opinion and an outline of the treatment, or so much 
of this as may possibly be of service to the consultant; and as 
soon as possible after the case has been seen and studied, the 
consultant should address the physician in charge and advise 
him of the results of the consultant's investigation of the case. 
Both these opinions are confidential and must be so regarded by 
the consultant and by the physician in charge. 

Discussions in Consultation 

Section 5. — After the physicians called in consultation have 
completed their investigations of the case, they may meet by 
themselves to discuss conditions and determine the course to be 
followed in the treatment of the patient. No statement or dis- 



MEDICAL ETHICS 825 

cussion of the case should take place before the patient or friends, 
except in the presence of all the physicians attending, or by their 
common consent; and no opinions or prognostications should be 
delivered as a result of the deliberations of the consultants, 
which have not been concurred in by the consultants at their 
conference. 

Attending Physician Responsible 

Section 6. — The physician in attendance is in charge of the 
case and is responsible for the treatment of the patient. Conse- 
quently, he may prescribe for the patient at any time and is 
privileged to vary the mode of treatment outlined and agreed on 
at a consultation whenever, in his opinion, such a change is 
warranted. However, at the next consultation, he should state 
his reasons for departing from the course decided on at the pre- 
vious conference. When an emergency occurs during the ab- 
sence of the attending physician, a consultant may provide for 
the emergency and the subsequent care of the patient until the 
arrival of the physician in charge, but should do no more than 
this without the consent of the physician in charge. 

Conelict or Opinion 

Section 7. — Should the attending physician and the consultant 
find it impossible to agree in their view of a case another con- 
sultant should be called to the conference or the first consultant 
should withdraw. However, since the consultant was employed 
by the patient in order that his opinion might be obtained, he 
should be permitted to state the result of his study of the case 
to the patient, or his next friend in the presence of the physician 
in charge. 

Consultant and Attendant 

Section 8. — When a physician has attended a case as a con- 
sultant, he should not become the attendant of the patient 
during that illness except with the consent of the physician who 
was in charge at the time of the consultation. 



826 THE PRINCIPLES OF THERAPEUTICS 

Article IV. — Duties of Physicians in Cases of 
Interference 

Criticism to be Avoided 

Section 1 . — The physician, in his intercourse with a patient 
under the care of another physician, should observe the strict- 
est caution and reserve; should give no disingenuous hints rela- 
tive to the nature and treatment of the patient's disorder; nor 
should the course of conduct of the physician, directly or indi- 
rectly, tend to diminish the trust reposed in the attending 
physician. 

Social Calls on Patient of Another Physician 

Section 2. — A physician should avoid making social calls 
on those who are under the professional care of other physi- 
cians without the knowledge and consent of the attendant. 
Should such a friendly visit be made, there should be no inquiry 
relative to the nature of the disease or comment upon the treat- 
ment of the case, but the conversation should be on subjects 
other than the physical condition of the patient. 

Services to Patient of Another Physician 

Section 3. — A physician should never take charge of or 
prescribe for a patient who is under the care of another physician, 
except in an emergency, until after the other physician has 
relinquished the case or has been properly dismissed. 

Criticism to be Avoided 

Section 4. — When a physician does succeed another physician 
in the charge of a case, he should not make comments on or 
insinuations regarding the practice of the one who preceded him. 
Such comments or insinuations tend to lower the esteem of the 
patient for the medical profession and so react against the critic. 

Emergency Cases 

Section 5. — When a physician is called in an emergency and 
finds that he has been sent for because the family attendant is 
not at hand, or when a physician is asked to see another physi- 



MEDICAL ETHICS 827 

cian's patient because of an aggravation of the disease, he should 
provide only for the patient's immediate need and should with- 
draw from the case on the arrival of the family physician after he 
has reported the condition found and the treatment administered. 

When Several Physicians are Summoned 

Section 6. — When several physicians have been summoned in 
a case of sudden illness or of accident, the first to arrive should 
be considered the physician in charge. However, as soon as the 
exigencies of the case permit, or on the arrival of the acknowl- 
edged family attendant or the physician the patient desires to 
serve him, the first physician should withdraw in favor of the 
chosen attendant; should the patient or his family wish some 
one other than the physician known to be the family physician 
to take charge of the case the patient should advise the family 
physician of his desire. When, because of sudden illness or 
accident, a patient is taken to a hospital, the patient should be 
returned to the care of his known family physician as soon as the 
condition of the patient and the circumstances of the case 
warrant this transfer. 

A Colleague's Patient 

Section 7. — When a physician is requested by a colleague 
to care for a patient during his temporary absence, or when, 
because of an emergency, he is asked to see a patient of a colleague, 
the physician should treat the patient in the same manner and 
with the same delicacy as he would have one of his own patients 
cared for under similar circumstances. The patient should 
be returned to the care of the attending physician as soon as 
possible. 

Relinquishing Patient to Regular Attendant 

Section 8. — When a physician is called to the patient of 
another physician during the enforced absence of that physician, 
the patient should be relinquished on the return of the latter. 

Substituting in Obstetric Work 

Section 9. — When a physician attends a woman in labor in the 
absence of another who has been engaged to attend, such 



828 THE PRINCIPLES OF THERAPEUTICS 

physician should resign the patient to the one first engaged, 
upon his arrival; the physician is entitled to compensation for 
the professional services he may have rendered. 

Article V. — Differences between Physicians 

Arbitration 

Section 1. — Whenever there arises between physicians a 
grave difference of opinion which cannot be promptly adjusted, 
the dispute should be referred for arbitration to a committee of 
impartial physicians, preferably the Board of Censors of a 
component county society of the American Medical Associa- 
tion. 

Article VI. — Compensation 

Limits of Gratuitous Service 

Section 1. — The poverty of a patient and the mutual 
professional obligation of physicians should command the 
gratuitous services of a physician. But institutions endowed 
by societies, and organizations for mutual benefit, or for acci- 
dent, sickness and life insurance, or for analogous purposes, 
should be accorded no such privileges. 

Contract Practice 

Section 2. — It is unprofessional for a physician to dispose 
of his services under conditions that make it impossible to 
render adequate service to his patient or which interfere with 
reasonable competition among the physicians of a community. 
To do this is detrimental to the public and to the individual 
physician, and lowers the dignity of the profession. 

Secret Division of Fees Condemned 

Section 3. — It is detrimental to the public good and degrad- 
ing to the profession, and therefore unprofessional, to give or to 
receive a commission. It is also unprofessional to divide a fee 
for medical advice or surgical treatment, unless the patient 
or his next friend is fully informed as to the terms of the trans- 
action. The patient should be made to realize that a proper 



MEDICAL ETHICS 829 

fee should be paid the family physician for the service he renders 
in determining the surgical or medical treatment suited to the 
condition, and in advising concerning those best qualified to 
render any special service that may be required by the patient. 



CHAPTER III 

THE DUTIES OF THE PROFESSION TO THE 
PUBLIC 

Physicians as Citizens 

Section i. — Physicians, as good citizens and because their 
professional training specially qualifies them to render this 
service, should give advice concerning the public health of the 
community. They should bear their full part in enforcing its 
laws and sustaining the institutions that advance the interests 
of humanity. They should cooperate especially with the 
proper authorities in the administration of sanitary laws and 
regulations. They should be ready to counsel the public on 
subjects relating to sanitary police, public hygiene and legal 
medicine. 

Physicians Should Enlighten Public 

Duties in Epidemics 

Section 2. — Physicians, especially those engaged in public 
health work, should enlighten the public regarding quarantine 
regulations; on the location, arrangement and dietaries of hospi- 
tals, asylums, schools, prisons and similar institutions; and con- 
cerning measures for the prevention of epidemic and contagious 
diseases. When an epidemic prevails, a physician must con- 
tinue his labors for the alleviation of suffering people, without 
regard to the risk to his own health or life or to financial return. 
At all times, it is the duty of the physician to notify the properly 
constituted public health authorities of every case of communi- 
cable disease under his care, in accordance with the laws, rules 
and regulations of the health authorities of the locality in which 
the patient is. 



s30 the principles of therapeutics 

Public Warned 

Section 3. — Physicians should warn the public against the 
devices practised and the false pretensions made by charlatans 
which may cause injury to health and loss of life. 

Pharmacists 

Section 4. — By legitimate patronage, physicians should 
recognize and promote the profession of pharmacy; but any 
pharmacist, unless he be qualified as a physician, who assumes 
to prescribe for the sick, should be denied such countenance and 
support. Moreover, whenever a druggist or pharmacist dis- 
penses deteriorated or adulterated drugs, or substitutes one 
remedy for another designated in a prescription, he thereby for- 
feits all claims to the favorable consideration of the public and 
physicians. 

THE OATH OF HIPPOCRATES, THE FATHER OF MEDICINE 

"I swear by Apollo, the physician, and Aesculapius, and 
Health, and All-heal, and all the gods and goddesses, that, 
according to my ability and judgment, I will keep this Oath and 
this stipulation to reckon him who taught me this art equally 
dear to me as my parents, to share my substance with him, and 
relieve his necessities if required; to look upon his off-spring 
on the same footing as my own brothers, and teach them this Art, 
if they wish to learn it, without fee or stipulation; and that 
by precept, lecture and every mode of instruction, I will impart 
a knowledge of the Art to my own sons, and those of my teachers, 
and to the disciples bound by a stipulation and oath, according 
to the law of medicine, and to none others. I will follow that 
system of regimen, which, according to my ability and judg- 
ment, I consider for the benefit of my patients, and abstain from 
whatever is deleterious and mischievous. I will give no deadly 
medicine to anyone if asked, nor suggest any such counsel^ and 
in like manner I will not give to a woman a pessary to produce 
abortion. With purity and holiness I will pass my life and 
practice my Art. I will not cut persons laboring under the 
stone, but will leave this to be done by men who are practitioners 



MEDICAL ETHICS 83 I 

of this work. Into whatever houses I enter, I will go into them 
for the benefit of the sick, and will abstain from every voluntary 
act of mischief and corruption; and, further, from the seduction 
of females or males, of freemen and slaves. 

"Whatever in connection with my professional practice or not 
in connection with it, I see or hear, in the life of men which 
ought not to be spoken of abroad, I will not divulge, as reckoning 
that all such should be kept secret. 

"While I continue to keep this Oath unviolated, may it be 
granted me to enjoy life and the practice of the Art, respected 
by all men, in all times! But should I trespass and violate 
this Oath, may the reverse be my lot ! " 

ETHICAL SUGGESTIONS TO THE YOUNG PRACTITIONER 

The above principles of the practice of medicine contained in 
the Oath of Hippocrates cannot be much improved upon even at 
the present day. 

It is much wiser for a physician who expects to specialize 
to do a certain amount of general practice first; it broadens 
him and prevents a narrow view of the art of medicine. If a 
physician immediately specializes after his hospital internship, 
he will not so well understand the bearing of general conditions 
on the part of the body on which he specializes. 

For some years, at least, it is wise to have the physician's 
office hours in the window or on the door, so that it may be 
readily learned when he is in his office. The office hours 
should be decided upon only after very careful deliberation. 
Too long published office hours and too many divisions of 
office hours are a mistake, and it is well for the physician 
to immediately start with the addition to the office hour 
sign, and to his cards, of the words, "and by appointment." 
At the present day it is rather unwise to begin to advertise 
evening office hours, although for some years the young prac- 
titioner may be in his office at certain hours on most evenings; 
but it is better to let these hours be "by appointment" so that 
the young physician may obtain a free evening without breaking 
his own rules and regulations. 

It is well to begin immediately to do the office work, as far 



832 THE PRINCIPLES OF THERAPEUTICS 

as possible, by appointments. Toward this end special appoint- 
ment cards should be printed, with the telephone number upon 
them, and with the request that, if the appointment must be 
broken, notification will be telephoned as soon as possible. By 
the appointment system the physician is not hurried, can give 
his patient all the time he requires, and can so distribute his 
work as to render the most efficient service. Also the appoint- 
ment system allows the physician to leave word at his office, or 
to send word to postpone an engagement, if he is unavoidably 
absent at the time the patient is to come. For many years 
he should rigidly keep his office hours. This does not mean 
that he should not have vacations, but it does mean that 
irregularity in being in his office, when he is supposed to be 
there, is a bad business principle. 

The doctor's sign should be a simple name plate, with or 
without initials as thought best. It should not state his 
specialty, or that he is a physician or a surgeon. The business 
card, which should be engraved, should state his office hours, 
"and by appointment, " and should also have on it his telephone 
number. 

The physician should have a copy of every prescription that 
he writes, preferably the stub system, like a check book, and 
the stub should state the dose of each drug given, the frequency 
of dosage, the patient's name, age and address, and the date 
the prescription was written. Under no circumstances should a 
physician use an advertising prescription blank offered him by 
a druggist. It is well within the physician's right to designate 
which druggists he thinks are the most reliable, but he should 
not advertise a druggist. Also a patient is likely to consider 
that the physician using advertising prescription blanks is 
interested financially in the fee charged for the filling of the 
prescription. 

The equipment of the office and waiting room should be 
simple, sanitary, attractive, and as complete as possible. 
Displays of instruments, skulls, anatomical pictures, or patho- 
logical specimens are entirely out of place. The magazines 
and papers in the waiting room should be of recent vintage 
and should not be antiques. 



MEDICAL ETHICS 833 

Although the following recommendation will not generally be 
popular, it is, nevertheless, not the height of refinement to 
have the physician's consulting room or waiting room smell of 
tobacco smoke. No more is it advisable for the physician 
himself to reek of tobacco, or of any antiseptic, or of any strong 
perfume. Smoking by the physician should be done outside 
of office hours, and better in other rooms. 

The young physician should not buy many periodicals, but 
as soon as possible he should join The American Medical 
Association, and, as a member, receive the Journal of that 
Association. It is unwise at first to buy systems of medicine; 
it is better to buy individual books that are standards on the 
subjects of which they treat. 

Before starting the practice of medicine in any city or 
village, the physician should visit the secretary of the local 
medical association, ascertain some of the rules and regulations 
of that association, how soon he will be eligible for membership, 
and learn the standard of fees of the region. He should make 
these fees his own, making such charitable deductions as every 
physician must make, and making charitable calls where they 
are deserved. 

If a physician is consulted by a pregnant woman who desires 
that abortion be produced, she must be courteously but firmly 
refused. No fee can be charged for such an office consultation. 

If a woman has delayed menstruation and wonders if she is 
pregnant and the condition is uncertain, the physician may 
write a prescription for her general condition, assuring her that 
if she is pregnant this medicine will not produce abortion, 
although if she is not pregnant, it may aid in promoting normal 
menstruation; else, if even the simplest prescription is given 
and the woman soon begins to menstruate, she will consider 
that the physician has given her something that may produce 
abortion. Such a patient should not be given medicine from 
the office. 

If a physician is called to a patient who is aborting or having 

a miscarriage, and the patient is a stranger to him and he does 

not know the conditions or the cause of the abortion, or if 

questioning shows that some artificial method has been used 

53 



834 THE PRINCIPLES OF THERAPEUTICS 

to produce the abortion, he should do nothing for the patient, 
except to stop dangerous hemorrhage, until he has sent for a 
consultant. He must do everything to save life, but must 
not accept the care of the patient without the protection of a 
medical consultant. 

The physician should be very careful not to give a certificate 
of disability or illness to a patient that does not exactly state 
what he personally knows about the patient. His dates must 
be accurate, and he must not certify to conditions which 
occurred before he saw the patient. Carelessness in giving 
certificates will soon cause his word to be doubted. 

If a charity case is accepted by a physician, he must continue 
to care for the patient until the illness terminates, unless he 
personally requests the department of charities of the city or 
town to send some other physician to take charge of the 
patient. If a physician knows the case to be one of charity, but 
it is an emergency, he should, if possible, attend the case, 
administer what treatment is necessary for the emergency, 
and then immediately withdraw from the case, if he does not 
care to continue the attendance. 

The professional visits on a seriously ill patient should be 
as nearly as possible at the same hour each day. This insures 
regular observations, and also allows the family and the nurse to 
know when to expect the physician. If a patient is seriously 
ill and there is likely to occur an emergency at night, it is well 
to make a late evening call, and to give thorough instructions to 
the nurse as to what to do during the night under certain condi- 
tions. Many times such evening calls prevent the disturbance 
of the doctor's sleep, and forewarning of possible emergencies is 
better for the nurse and for the patient as well as for the doctor. 

All directions to the nurse, or to the one in whose care the 
patient is, must be explicit, and generally it is best to write 
the directions. 

Hysterical patients are the most troublesome, but if the 
physician can relieve their disturbances, they become the most 
loyal of patients. Many times it should be recognized that a 
hysterical condition means a disturbance that has not been 
diagnosed; something is the matter with the patient. Conse- 



MEDICAL ETHICS 835 

quently, their pains and aches should rarely be belittled; and 
it is not often wise to tell the family that the condition is due 
to hysteria. 

Where patients are seriously ill and the medication is likely 
to be changed, perhaps daily, it is unwise to order more than 
small quantities of the drugs or preparations required. 

Most prescriptions for hypnotics should contain the request 
to the druggist that "it be not repeated;" and whenever a 
hypnotic, a narcotic, or a poisonous drug is given, the physician 
should not dismiss that patient until he knows the drug has 
been stopped. 

When a physician is called to a patient who has been treated 
by another physician, and he does not know that fact until he has 
arrived at the patient's house, he should refuse to care for the 
patient until he knows that the other physician has been dis- 
missed and that his charges have been paid. On the other hand, 
if possible, he should generally notify the physician that he has 
been called to his patient, and seek consultation, to learn first 
hand the story of the case and the cause for the family's desire 
to change physicians. If a physician assumes charge of another 
physician's patient, he must exercise great care lest he say some- 
thing that would be derogatory to the other physician. Many 
times it is not even necessary to look over the prescriptions of 
the previous physician, as it is much better to give the treatment 
which seems advisable without criticising what has been pre- 
viously given. 



INDEX 



Abbreviations for prescription writ- 
ing, 32 
ABC mixture, 87 
Abderhalden ferment tests, 549 
Abdomen, cold applications to, 670 
contraindications, 665 

fluid in, removal of, 536 

hot applications to, 669 
Abdominal operations, pituitary ex- 
tracts after, 455 
Absolute alcohol, 238 
Absorption of drugs, rapidity of, 44 

varying rate of, modifying action of 
drugs, 40 
Acacia, 46 
Acapnia, 312 

Accommodation, paralysis of, atropine 
for, 252, 255 
homatropine for, 255, 256 
A. C. E. mixtures, 316 
Aceta, definition, 23 
Acetanilid, 46 

action, 334 

administration, S33 

as analgesic, 336 

as antipyretic, 333 

over-action, 335 

poisoning, treatment, 335 

toxic action, 335 

uses,335 
Acetanilidum, 46 
Acetannin, as astringent, 145 
Acetate of lead, 85, 732 
Acetphenetidin, 46 

action, 337 

administration, 336 

as antipyretic, 336 
Acetphenetidinum, 46 
Acetum scillae, 92 
Acetylsalicylic acid, 258, 332, 376, 377 

in rheumatism, 377 
Acid, acetylsalicylic, 258, 332, 376, 377 
in rheumatism, 377 

arsenous, 53, 382 

boracic, 47 

boric, 47 

as dusting powder, 127 

carbolic, 84, 119 
liquefied, 84 
ointment of, 84 

chromic, 63 

as escharotic, 138 

citric, 47 

diethylbarbituric, 282 



Acid, glacial acetic, 47 
as escharotic, 138 
hydrochloric, diluted, 47 
as aid to digestion, 151 
as appetizer, 149 

importance of, 506 
lactic, bacilli in intestinal putre- 
faction, 173 
muriatic, diluted, 47 
nitric, 48 

as escharotic, 138 
parasulphondichloraminobenzoic, as 

antiseptic, 118 
phenylcinchoninic, 48 

in gout, 373 

to increase uric acid excretion, 398 
phenylethylbarbituric, 283 
phosphoric, diluted, 48 
picric, 99 

as emollient, 130 
pyrogallic, 89 
salicylic, 48, 376 

as escharotic, 139 

in rheumatism, 375 
sodium phosphate to render urine 

acid, 192 
tannic, 48 

as antidote in poisoning, 143 

as astringent, 143 
tartaric, 49 
trichloracetic, 49 

as escharotic, 138 
uric, production of, 586 
urine, drugs used to cause, 192 
Acidity, drugs used to reduce, 106 
of urine, 582 

treatment, 190 
Acidosis, glucose solutions for, 605 
in anesthesia, 288, 289 
prevention of, before operation, 294 

in fever, 327, 329 _ 
Acidum aceticum glaciale, 47 
acetylsalicylicum, 376 
boricum, 47 
citricum, 47 
hydrochloricum dilutum, 47, 149, 

nitricum, 48 

phenylcinchoninicum, 48 
phosphoricum dilutum, 48 
salicylicum, 48 
tannicum, 48 
tartaricum, 49 
trichloraceticum, 49 



837 



S 3 8 



INDEX 



Acne, 785 

ichthyol in, 131 
Aconite, 49 

action, 212 

administration, 212 

over-action, 212 

poisoning, treatment, 212 

tincture of, 49 

to depress heart, 212 

toxic action, 212 

uses, 212 
Aconitina, 49 
Aconitum, 49 
Acquired immunity, 547 
Acromegaly, pituitary disturbances in, 

45i 
Action and uses of valuable drugs, 109 

of a drug, conditions modifying, 40 
Addiction, cocaine, 723 
Addicts, drug, regulated treatment of, 

723 
treatment at Riverside Hospital, 
N. Y., 724 
Addison's disease, pigmentation in, 464 
pituitary extracts in, 469 
relation to suprarenal glands, 461 
suprarenal extracts in, 469 
symptoms, 464 
Adenoids in nasopharynx and pituitary 

disturbances, 453 
Adeps benzoinatus, 49 
lanae, 50 

hydrosus, 50 
Adhesive plaster, 732 
Adiposis dolorosa, thyroid preparation 

for, 436 
Administration of drugs, 44 

disguising disagreeable tastes, 32 
Adrenal insufficiency suprarenal feed- 
ing in, 468 
Adrenalin, 459 
Adrenin, 459 
Adults, exercises for, 686 
^Ether, 50 

^Ethylis chloridum, 50 
^Ethylmorphinae hydrochloridum, 261 
African arrow-poison, 226 
Agar-agar as laxative, 161, 614 
Age and height, weight for, table of, 39 
computing dosage according to, rule 
for, 38 
Agglutinins, 549 
tests for, 549 
Air, hot, hyperemia by means of, 633 

ocean, 699 
Albumin in urine, 189 
Albuminuria following cold appli- 
cations, 664 
Alcohol, 595 
absolute, 238 
action, 239 

on gastro-intestinal tract, 239 



Alcohol, action on mucous membranes, 

239 
on skin, 239 

administration, 238 

as substitute for food, 239, 242 

as vasodilator, 237 

content of liquors, 595, 596 

dehydratum, 238 

denatured, 238 

dilutum, 238 

enema, 606 

ethyl, 238 

harmful effects of, 240 

in syncope, 242 

injections in trigeminal neuralgia, 
242 

internal therapeutic use of, 242, 243 

methyl, 238 
poisoning, 764 
symptoms, 765 
treatment, 765 

narcotic effect of, 713 

over-action, 240 

pack for sprains and joints, 241 

poisoning, 711 
treatment, 241 

rubbing, 667 

sponging, 667 

toxic action, 241 

uses, 241 

wood, 238 

poisoning, 764 
symptoms, 765 
treatment, 765 
Alcoholic patients, anesthetic for, 289 
Alcoholism, 711 

Alcresta ipecac as anthelmintic, 182 
Ale, alcohol content of, 596 
Alexines, 548 

Alkaline antiseptic tablet for atomi- 
zation, 517 

springs, 709 

urine, drug used to cause, 190 

waters, 709 
Alkalinization of infant foods, 589 
Alkalosis due to extirpation of para- 
thyroids, 443 
Allen- Joslin diet in diabetes, 624 
Allergy, 550, 553 
Aloes, 50 

as laxative, 161 

pill of, prescription for, 51 
Aloin, 50 

pill for constipation, formula for, 
162 
Aloinum, 50 

Alpine sun lamp for heliotherapy, 637 
Altitude high, effects of, 700, 701 

of health resorts, 700 
Alum, 51 

burnt, 51 

dried, 51 



INDEX 



839 



Alumen, 51 

exsiccatum, 51 
Alumini hydroxidum, 51 
Aluminum betanaphtholsulphonate, as 

dusting powder, 128 
Alumnol as dusting powder, 128 
Always-ready handbag, 810 
Alypin and stovaine as local anesthetic, 

325 
Ameba of intestines, 175 
Amebic dysentery, anthelmintics for, 
181 
treatment, 181 
Amenorrhea, 195, 196 

corpus luteum in, 475, 476, 477 
period, relation to lactation, 486 
thyroid preparations for, 436 
with overweight, corpus luteum in, 
476 
American hellebore, 99, 213 

Medical Association, Council on 
Pharmacy and Chemistry of, 

3i 
ethics of, principles of, 819-831 
wormseed oil, 78 
Amines, 581 
Amino-acids, 579, 580 
Ammoniated mercury, 72 
Ammonii carbonas, 51 

chloridum, 52 
Ammonium carbonate, 51 
chloride, 52 
action, 202 
administration, 201 
as expectorant, 201 
uses, 202 
Ampere, 639 
Amphibian larvae, effects of endocrine 

therapy in, 412 
Amyl nitrite, 52, 244 

action, 245 
Amylis nitris, 52 
Analgesics, 108 
Anaphylactic reaction, prevention of, 

552 
Anaphylatoxin, 551 
Anaphylaxis, 550, 551, 553 

drug, 42 
Anasarca of nephritis, pilocarpine in, 

185 

Anelectrotonus, 641 
Anemia, 196 

bone marrow extracts in, 511 

diet in, 621 

iron in, 397 

symptoms of, 398 

treatment, 397 
Anesthesia, acidosis in, 288, 289 

chloroform, death rate in, 288 

Crile's method of conducting, 287 

death due to, 286 

ether, death rate in, 288 



Anesthesia, ether, drop method in, 313 
general, by rectum, 291 

care of patient in operating room, 

296 
chloroform in, 304 
drugs used to cause, 109, 284 
ether in, 309 

nitrogen monoxide in, 313 
nitrous oxide-oxygen, in, 314 
oxygen inhalations in, 315 
pre-operative care of patient, 292 
preparation of patient for opera- 
tion, 294 
hiccough in, 298 
infiltration, 316 

epinephrine in, 319 
local, apothesine in, 325 
benzyl alcohol in, 325 
beta-eucaine hydrochloride in, 324 
by cold applications, 663 
cocaine hydrochloride in, 321 
drugs used to cause, 109, 316 

efficiency of, 317 
ethyl chloride in, 325 
holocaine hydrochloride in, 324 
infiltration, 316 
novocaine in, 325 
procaine in, 325 

scopolamine and morphine in, 319 
spinal, 320 

stovaine and alypin in, 325 
partial, danger of, 286 

for removal of dressings, 302 
rectal, 287, 290, 291 

contraindications for, 292 
indications for, 292 
spinal, 320 
Anesthetics, 109, 259 
choice 0^289 
general, 284 
local, drugs used to cause, relative 

toxicity of, 318 
repeated administration of, 288 
Anesthetist, expert, necessity of, 285, 
290 
table for, in operating room, 302 
Anesthol, 35 

Angina pectoris, nitrites in, 246 
Angioneurotic edema, 780 
Anhydrous lanolin, 50 
Anions, 643 
Anise for intestinal flatulence in babies, 

158 
Ankle, sprained, hot foot bath for, 669 
Anoci-association, 287, 316 
Antacids, 106, 152 

Anterior poliomyelitis, treatment, 574 
Anthelmintics, 107, 175 
for amebic dysentery, 181 
for hook-worms, 179 
for pin-worms, 178 
for round-worms, 177 



840 



INDEX 



Anthelmintics for tape- worms, 175 
Antibodies in immunity, 549 
Antidiptheric serum, 564 
dried, 564 
purified, 564 
Antidote for arsenic poisoning, 69, 386 

in poisoning, atropine as, 256 
Antidysenteric serum, 569 
Antifebrin, 46, 333 
Antimeningococcic serum, 573 
Antimonii et potassii tartras, 52 
Antimony and potassium tartrate, 52 
Antineuritic vitamines, 583, 584 

in milk, 585 
Antipneumococcic serum, 568 
Antipyrina, 52 
Antipyrine, 52 

action, 337 

administration, 337 

as antipyretic, 337 

over-action, 337 

uses, 338 
Antipyretics, 109, 325, 332 

in fever, 330 
Antirabic vaccine, 564 
Antiscorbutic vitamines, 583 
Antiseptic ointments, 132 
Antiseptics, 105, no, 116 
Antispasmodics, 248 
Antitetanic serum, 565 
dried, 565 
purified, 565 
Antitoxic serums, official, 564 
Antitoxin, 564 

bacillus botulinus, 767 

tetanus, 568 

treatment of diphtheria, 566 
Antrum disease, nasal douching for, 

5i9 - 
Aortic insufficiency, digitalis in, 222 
stenosis, broken compensation in, 
digitalis in, 222 
Aphorisms, drug, 803 
Apoplectic attack, 744 
Appetite, 577 

drugs used to increase, 106 
Appetizers, bitter, 149 
Apple, bitter, as irritant purgative, 

172 
Apomorphinae hydrochloridum, 53 
Apomorphine hydrochloride, 53 
action, 157 
administration, 157 
as emetic, 156, 157 
uses, 157 
Aposthesine as local anesthetic, 325 
Apothecaries system in prescription 

writing, 28 
Aqua camphorae, 60, 256 
cinnamomi, 78 
hamamelidis, $3 
menthae piperitae, 80 



Aquae, definition, 23 
Argenti nitras, 53 
fusus, 53, 147 

as escharotic, 139 
Argyria, 147 
Argyrism, 147 
Argyrol, 148 
Aristol, 98 
Aromatic elixir, 67 

fluidextract of cascara, 62 
spirit of ammonia, 51 
syrup of rhubarb, 91 
tincture of rhubarb, 91 
Arseni iodidum, 53, 383 

trioxidum, 53, 382 
Arsenic, action, 384 
administration, 383 
antidote, 69 
as germicide, 389 

as stimulant to metabolism, 382, 
388 
to production of blood corpuscles, 

389 
to skin, 183, 389 
as tonic, 388 
in metabolism, 382, 388 
iodide, 383 
over-action, 385 
poisoning, 731 

acute, treatment, 386 
chronic, 387 
treatment, 388 
springs, 709 
toxic action, 385 
trioxide, 53 
uses, 388 
water, 709 
white, 53,382 
Arsenous acid, 53, 382 

iodide, 53 
Arsphenamine as specific, in syphilis, 

345, 347 
in locomotor ataxia, 347 
intravenous injection of, epinephrine 
^ before, 349, 470 
Kolmer and Yagle's 
conclusions concerning, 349 
Arsphenaminized serum, preparation 

of, 348 
Art of prescription writing, 17 
Arteriosclerosis, iodides in, 393 
Arthritis, chronic, climate for, 705 
Artificial respiration in opium poison- 
ing, 266 
Schafer method, 752 
Sylvester method, 752 
Asafetida, 54 
Ascaris lumbricoides, 175 
Aspidium, 54 

for tape- worms, 175, 176 
oleoresin of, 55 
Aspidosperma, 54 



INDEX 



841 



Aspidospermine, 55 
Aspiration, 535 

for removal of pus, 536 
Aspirin, 258, 332, 376, 377 

in rheumatism, 377 
Asthma, acute, treatment, 207 

atropine in, 253 

change of climate in, 704 

drugs used to relax spasm in, 206 

epinephrine in, 469 

ergot in, 235 

inhalations in, 516 

nitrites in, 246 

nitroglycerin in, 247, 470 

suprarenal gland extract in, 469 

thyroid extract in, 439 
Astringent action, objects of, 142 

metals, 142 

wash, 143 
Astringents, 106, 141 

indications for use of, 142 
Ataxia, vasomotor, 691 
Athletes, life of, 688 
Athletics, competitive, 688 

so-called, 687 
Atlantic coast health resorts, 702 
Atomization, 517 

oil sprays for, 518 

solution for, 517 
Atophan, 48 

in gout, 373 

to increase uric acid excretion, 398 
Atoxyl, 383 
Atropa belladonna, 55 
Atropina, 55 
Atropinae sulphas, 55 
Atropine, 55 

action, 251 

on circulation, 209 

administration, 250 

and morphine for postoperative 
vomiting, 299 

as antidote in morphine habit, 718, 
721 
in poisoning, 252, 256 

as cerebral stimulant, 250 

for aborting cold, 254 

for intestinal spasm, 158 

in asthma, 253 

in bladder irritability, 253 

in eye inflammations, 255 

in intestinal colic, 253 

in neuralgia, 252 

indications for use of, 252 

over-actions, 251 

poisoning, treatment, 252 

to dilate pupils and paralyze accom- 
modation, 252, 255 

to dry up secretions, 252, 253 

to inhibit or dull peripheral nerve 
irritation and hyperexcitability, 
252 



Atropine to stimulate brain and 
nervous centers, especially res- 
piratory, 252, 254 
heart and raise blood-pressure, 

252, 254 
smooth muscle tissue, 252, 254 
toxic action, 252 
Auricular fibrillation, digitalis in, 224 
Autocondensation, 649 
Autogenous vaccines, 556 
Axillae, sweating of, 796 

Bacillary dysentery, treatment, 569 
Bacilli, lactic acid, in intestinal putre- 
faction, 173 
Bacillus acidophilus, 616 

cultures of, to change intestina 

flora, 617 
in intestinal putrefaction, 1 74 
acnes vaccines, 556 
bifidus, 616 
botulinus, 766 

antitoxin, 767 
bulgaricus in intestinal putrefaction, 
173, 617 
Bacteria, growth of, in kidneys and 
bladder, drugs used to prevent, 
107, 193 
on body, drugs used to inhibit, 105 
intestinal, 616 
protective power of blood against, 

548 
putrefactive, in intestines, 616 
treatment for, 618 
Baking, body, cabinets for, 662 
Balneotherapy, 657 
Balsam of Peru, 55 

of Tolu, 55 
Balsamum Peruvianum, 55 

tolutanum, 55 
Bananas, 593 
as laxative, 615 
1 pound, calories in, 591 
Barber's itch, 790 
Barbital, 282 
action, 282 
as hypnotic, 271, 282 
description, 282 
over-action, 283 
poisoning, treatment, 283 
uses, 283 
Barbital-sodium, 282 
Barium sulphate for roentgen-ray 

examinations, 156 
Bark, calisaya, 63 
Peruvian, red, 63 
yellow, 63 
Basal metabolism in Graves' disease, 

425 

Bass' detoxication treatment of mala- 
ria, 365 

Bath, carbon dioxide, 672 



842 



INDEX 



Bath, cold, effects of, 657 

electric light, 662 

foot, 671 

hot, effects of, 657, 658 
sitz, 671 

mud, 672 

Nauheim, 672 

pine needle, 672 

Russian, 661 

sea salt in, 671 

sulphur, 672 

sun. See Sun bath. 

sweat, 661 

Turkish, 660 

warm, effects of, 658, 659 
Bathing in contagious disease, 114 
Beans, baked, 1 pound, calories in, 591 
Beef juice, preparation of, 620 
Beer, alcohol content of, 596 
Belladonna, 55 

administration, 249 

as cerebral stimulant, 249 

liniment, 55 

ointment, 55 

plaster, 55 
Belladonnas folia, 55 

radix, 55 
Bends, 751 
Benne o,il, 81 
Benzene in leukemia, 182 
Benzoate of sodium, 93 
Benzoin, 56 

tincture of, 56 

for inhalation, 515 
Benzoinated lard, 49 
Benzoinum, 56 
Benzol in leukemia, 182 
Benzosulphinidum, 56 
Benzyl alcohol as local anesthetic, 325 

benzoate, 261, 717 
miscible, 261 

to relax spasm and quiet pain, 
261, 262 
Beriberi, diet in, 630 
Beta-eucainae hydrochloridum, 56, 324 
Beta-eucaine hydrochloride, 56 

as anesthetic, 324 
Betanaphthol, 56 

as anthelmintic, 178 

in intestinal putrefaction, 173 
Betul, oil of, 77, 376 
Bicarbonate of soda, 93 
Bichloride of mercury, 71 

as antiseptic, 116 
Bier's hypermic treatment, 632 
by constriction, 632 
by dry cupping, 633 
by hot air, 633 
methods of producing, 632 
Bile as laxative, 162 

salts, 508 
Biniodide of mercury, 72 



Birch, sweet, oil of, 77 
Bismuth betanaphthol, 57 
for gastric irritation, 155 
milk of, 57 

preparations as dusting powders, 127 
subcarbonate, 57 
action of, 154 
administration, 154 
as digestant, 151 
uses, 155 
subgallate, 57 
subnitrate, 57 

for gastric irritation, 153 
tribromphenate, 156 
Bismuthi betanaphtholas, 57 
for gastric irritation, 155 
subcarbonas, 57 
subgallas, 57 

for gastric irritation, 155 
subnitras, 57 

for gastric irritation, 155 
tribromphenas, 156 
Bitartrate of potassium, 86 
Bites, mosquito, 780 
Bitter appetizers, 149 

apple as irritant purgative, 172 
tonic, nux vomica as, 228 
wood, 89 
Black-heads, 785 

Bladder, growth of bacteria in, drugs 
used to prevent, 107, 193 
infection of, salol in, 382 
irrigations, 531 

solutions for, 531 
irritability, atropine in, 253 
Blaud's pills, 394 
Blister, drugs used to, 106 

placing of, 137 
Blistering, 133 

drugs used for, 106 
plaster of cantharides for, 135 
Blood, concentration of, in gassing, 
death due to, 749 
corpuscles, arsenic to stimulate 

production of, 389 
protective power of, against bacteria 

548 
transfusion of , 543. See also Trans- 
fusion of blood. 
Blood-letting. See Venesection. 
Blood-pressure, atropine to raise, 252, 

254 
effects of altitude on, 700 
high, chloral in, 279 

climate for, 700, 705 

cold applications contraindicated 
in, 665 

corpus luteum in, 476 

nitroglycerin in, 247 

of menopause, corpus luteum in, 

477 
increasing, thyroid extract in, 439 



INDEX 



843 



Blood-vessels, drugs used to contract, 
108, 231 
to dilate, 108, 235 
Blue mass, 71, 339 
methylene, 77 
ointment, 71 
pill, 71, 339 
vitriol, 66 

as escharotic, 139 
Bluestone, 66 

Body baking, cabinets for, 662 
Boiled milk, 588 

water, 602 
Boils, 787 
multiple yeast for, 510, 788 
treatment of, 563 
vaccination for, 563 
yeast in, 510, 788 
Bone growth, relation of thymus 
gland to, 495, 49^ 
marrow, 511 

extracts in anemia, 511 
Boracic acid, 47 
Borate of sodium, 93 
Borax, 93 

Borcherdt's malt sugar, 616 
Boric acid, 47 

as dusting powder, 127 
solutions as gargles, 521 
Botulism, 618, 766 
symptoms, 767 
treatment, 767 
Bowels, care of, after operation, 300 
before operation, 294 
in fever, 329 
drugs used to evacuate, 107 
Bowling as exercise, 685 
Brain, 509 

and cord, syphilis of, 346 

and nervous centers, atropine to 

stimulate, 252, 254 
drugs used to depress, 108, 257 

to stimulate, 108, 248 
edema of, ergot in, 233 
extracts, 509 

in hemophilia, 509 
lipoid, 510 
Brand treatment in t>phoid fever, 666 
Brandy, alcohol content of, 596 
Brass founders' chills, 738 
Bread, wheat, 1 pound, calories in, 591 
Breakfast, 608 

Breast. See Mammary glands. 
Breathing exercises, value of, 513 
Broken compensation in aortic steno- 
sis, digitalis in, 222 
Bromide of potassium, 86 
as hypnotic, 272 
of sodium, 493 
as hypnotic, 272 
Bromides, action, 272 
as hypnotic, 275 



Bromides, by rectum, 606 

description, 272 

habit, symptoms, 273 
treatment, 274 

in cerebral excitement, 274 

in epilepsy, 275 _ 

in spinial irritation, 274 

in strychnine poisoning, 275 

over-action, 273 

poisoning, treatment, 274 

to prevent cinchonism, 275 

toxic action, 275 

uses, 274 
Bromism, 273. See also Bromide 

habit. 
Bronchitis, ammonium chloride form- 
ula for, 202 

climate for, 705 

cod-liver oil in, 206 

subacute, iodides in, 392 

tonic prescription for, 205 
Brown mixture, 52, 70 
Buchu, 58 

as diuretic, 190 
Bulgarian bacilli tablets in intestinal 

putrefaction, 174 
Burns, 753 

Carrel-Dakin solutions in, 755 

first degree, treatment, 753 

liquid petroleum for, 756 

of eye, 756 

paraffin treatment of, 755 

second degree, treatment, 753 

suprarenal extracts in, 468 

third degree, 755 
Burnt alum, 51 
Burow's solution, as astringent wash, 

143 
Butter, cacao, 81 

fat content of, 597 

peanut, 591 
Buttermilk, 589 

Cabinet, electric light, treatment, 662 

for body baking, 662 
Cacao butter, 81 
Cacodylate of sodium, 93 
Cade, oil of, 78 
Caffeina, 58 

citrata, 58, 214 

effervescens, 58, 214 
Caffeinae sodio-benzoas, 58, 214 
Caffeine, 58 

action, 214 

on circulation, 210 

administration, 214 

and sodium benzoate, 58 

as cerebral stimulant, 217 

as circulatory stimulant, 216 

as diuretic, 190 

citrated, 58 

effervescing, 58 



8 4 4 



INDEX 



Caffeine, over-action, 215 

poisoning, 216 

to strengthen heart, 214 

uses, 216 
Caffeol, 604 
Caisson disease, 750 
Calcined magnesia, 76 
Calcii carbonas praecipitatus, 58, 353 
as antacid, 153 

chloridum, 59, 352 

glycerophosphas, 59, 352 

lactas, 59, 352 

sulphidum crudum, 59 
Calcium, 59, 599 

action of, 353 

as specific in tetany, 352 

carbonate, precipitated, 58 

chloride, 59, 352 

enema, 606 

glycerophosphate, 59, 352 

hydroxide, solution of, 352 

in hyperthyroidism, 409 

in last months of pregnancy, 444 

in symptoms caused by parathy- 
roidectomy, 441 

in tuberculosis, 443 

lactate, 59, 352 

lactophosphate, syrup of, 353 

metabolism, control of, by para- 
thyroid glands, 441 
in pregnancy, 354, 356 

oxide, 60 

salts, 599 

sulphide, crude, 59 

waters, 709 
California, southern, health resorts of, 

702 
Calisaya, 357 

bark, 63, 357 

elixir of, 63 

as appetizer, 149 
Calomel, 71, 339 

as purgative, 166 

description, 339 

in syphilis, 346 
Calorie, definition, 576 
Calories, average daily need, 577 
Caloric value of food, table snowing, 

Calx, 60 

chlorinata, 60 
Camphor, 60 

action, 256 

on circulation, 210 

administration, 256 

as carminative, 257 

as cerebral stimulant, 248, 256 

in circulatory depression, 257 

in shock, 257 

over-action, 257 

uses, 257 
Camphora, 60 



Camphorated oil, 74 

as counterirritant, 133 

tincture of opium, 82 
Cancer, incurable, morphine in, 269 

mammary, relation of ovaries and 
corpus luteum to, 475 

of cervix, radium in, 655 

value of radium in treatment, 654 
Cane sugar, 594 
Canker sores in mouth, nitrate of 

silver for, 147, 523 
Cannabis, 61 

Indica, 61 
Canned goods, poisoning by, 766 
Cantharides, 61 

plaster of, for blistering, 135 
Cantharis, 61 

Capsicum ointments as counterirri- 
tant, 135 
Capsules, elastic, 34 

hard gelatin, 34 

in administration of drugs, 34 

soft gelatin, 34 
Carbo ligni, 61 
Carbohydrates, 591 

before operation, 294 

in fever, 328, 329 

tolerance, in Graves' disease, 409 
Carbolic acid, 84, 119 
liquefied, 84 
ointment of, 84 
Carbon dioxide bath, 672 

in emergencies after anesthesia, 

303, 304 
snow as escharotic, 140 
monoxide poisoning, 745 
treatment, 747 
Carbonate of zinc, precipitated, 99 
Carbonated springs, 708 

waters, 708 
Carbonic oxide gas, coma from, 744 
Carbuncles, 788 
treatment of, 563 
vaccination for, 563 
yeast in, 510 788 
Cardiac failure and shock with low 
blood-pressure, post-pituitary 
extract in, 455 
in ether anesthesia, treatment, 312 
Care of patient after operation, 298 

in operating room, 296 
Cargentos, 148 

Carlsbad salt as saline purgative, 170 
Carminatives, 106, 157 
Carotin, 593 
Carotinemia, 593 

Carrel-Dakin solutions for burns, 755 
Carriers, 616 

in contagious disease, in 
Carron oil, 74, 353 

Carter and Mayne treatment for 
malarial plasmodia in blood, 365 



INDEX 



845 



Carvacrol as anthelmintic, 180 
Cascara sagrada, 62 
as laxative, 163 
fluidextract of, 62, 163 
aromatic, 62 
Cassia, oil of, 78 
Castor oil, 80 

as purgative, 167 
disguising in prescriptions, 32 
Castration during menstrual life, 
effects of, 481 
in male, effects of, 489 
transplantation of testicles in, 490 
Cataphoresis, 643 
Cataract, radium in, 656 
Catarrhal jaundice, ammonium chlo- 
ride in, 203 
Cathartic pill, compound, 71 

as irritant purgative, 172 
springs, 708, 709 
waters, 708, 709 
Cathartics, 107, 158 

administration of, before operation, 

294 
contraindications for, 159 
indications for, 159 
Catheterization after operation, 301 
Cathions, 643 
Caustic, lunar, 53, 147 
potash, 88 

asescharotic, 139 
soda, 94 

as escharotic, 140 
Cautery for counter irritation, 136 
Cells of Ley dig, 490 
Central nervous system, drugs used 

for action on, 108, 247 
Cephaelin, 203 
Cerates, definition, 23 

simple, 62 
Ceratum, 62 

cantharides, 61 
Cereals, laxative, 614 

vitamines in, 585 
Cerebral excitement, bromides in, 274 

ergot in, 714, 715 
Cerebrin, 598 
Cerebrospinal depressants, 258 

fluid relation of, to delirium tremens, 
716 
types of conditions that produce 
changes in, 569 
inflammation, acute, ergot in, 233 
meningitis, acute, ergot in, 234 
morphine in, 269 
treatment of, 573 
Certified milk, 588 
Cervix, cancer of, radium in, 655 
Chalk mixture, 65, 253 
precipitated, 58, 353 
prepared, 65, 353 
Champagne, alcohol content of, 596 



Change of life. See Menopause. 
Chapped hands, 783 
Charcoal, wood, 61 
Chart-therapeutic, 809 
Cheese, 590 

1 pound, calories in, 591 
Chemical incompatibility, 36 
Chenopodium, oil of, as anthelmintic, 

180 
Cherry, wild, 89 
syrup of, 89 
Chest, fluid in, removal of, 536 
Chilblains, 773, 784 
Children, eczema of, 782 

exercises for, 684 

normal, weight of, 38 

young, convulsions of, 768 
Chills, brass founder's, 738 

spelter, 738 
Chiropractic, 680 
Chloral, 62 

habit, 277 

hydrate, 62 
action, 276 
administration, 276 
as hypnotic, 276, 278 
over-action, 277 
poisoning, 277 
chronic, 278 
treatment, 277 
toxic action, 277 
uses, 278 
Chloralum hydra turn, 62 
Chloramine-T as antiseptic, 118 
Chloride of lime, 60 

of zinc as escharotic, 140 
Chlorinated lime, 60 
Chlorine poisoning, 748 
Chloroform, 63 

action, 305 

administration, 304 

anesthesia, death rate in, 307 

as anesthetic, 304 

contraindications, 307 

danger of use in gas-lighted room, 
308 

indications for, 306 

liniment, 75 

as counterirritant, 304 

poisoning, treatment, 308 

toxic action, 307 

uses, 308 
Chloroformum, 63 
Chlorosis, iron in, 397 

thyroid preparation for, 435 
Chocolate, fat content of, 597 

in administering drugs to children, 32 
Cholesterin, 597 
Cholesterol, 597 
Chorea, treatment of, 574 
Chromic acid, 63 

as escharotic, 138 



8 4 6 



INDEX 



Chromii trioxidum, 63 
Chromium trioxide, 63 
as escharotic, 138 
Chrysarobin, 63 

ointment, 63 
Chrysarobinum, 63 
Cinchona, 63, 357 

red, 63, 357 

rubra, 63, 357 

tincture of, 63, 357 
as appetizer, 149 
compound, 357 
Cinchonidia, 64 
Cinchonidinae sulphas, 64, 357 
Cinchonidine sulphate, 64 
Cinchonism, 361 

bromides to prevent, 275 
Cinchophen, 48 

for pains in acute gout, 398 

in gout, 373 

to increase uric acid excretion, 398 
Cinnamon, oil of, 78 

water, 78 
Circulation, condition of, before ad- 
ministration of anesthetic, 292 

drugs used for action on, 108, 207 
Circulatory depression, camphor in, 
257 

insufficiency, progressive, reasons 
for, 208 
Citrate of potassium, effervescent, 87 

of sodium, 93 
Citrated caffeine, 58 
effervescing, 58 
Citric acid, 47 

syrup of, 47 
Claret, alcohol content of, 596 
Climate, 698 

different, indications for, 704 
rules for sending patient to, 703 

driest, 703 

for tuberculous, 703, 705 

hill, 703 

in asthma, 704 

in bronchitis, 705 

in chronic arthritis, 705 

in emphysema, 705 

in gout, 705 

in hay fever, 704 

in high blood-pressure, 705 

in neurasthenia, 705 

in neuritis, 705 

inland, 701 

mountainous, 702 
effects of, 701 
Clinical histories, 807 
Clothing, disinfection of, 113 
Cloves, oil of, 78 
Coagulation of blood, brain extracts in, 

509 
Coagulose in hemorrhage, 371 
Coca, 321 



Coca-cola, 604 

habit, 216 
Cocaina, 64 

Cocainae hydrochloridum, 64 
Cocaine, 64 
habit, 323, 722 
hydrochloride, 64 
action, 322 
administration, 321 
as local anesthetic, 321 
habit, 323, 722 

treatment, 324 
over-action, 323 
poisoning, treatment, 323 
uses, 324 
with epinephrine for local anesthesia, 
47i 
Cocoa bean, 605 
Cocoanuts, fat content of, 597 
Codeina, 64 
Codeinae phosphas, 64, 260 

sulphas, 64, 260 
Codeine, 64, 260 

in troublesome coughing, 270 
Cod-liver oil, 80 

disguising in prescriptions, 32 
in bronchitis, 206 
in rickets, 583, 630 
Coffee, 603 

habit, 216 
Coils, cold, 665 
Colchici semen, 64 
Colchicina, 64, 373 
Colchicine, 373 
Colchicum seed, 64 
action, 373 _ 
administration, 373 
as specific in gout, 371, 373 
over-action, 373 
poisoning, treatment, 374 
toxic action, 374 
uses, 374 
Cold applications, 663 

albuminuria following, 664 
contraindications for, 664 
local anesthesia by, 663 
to abdomen, 670 

contraindications, 665 
to reduce temperature, frequency 
of, 664 
baths, effects of, 657 
coil, 665 
compresses, 665 
for systemic effect, 663 
local action of, 670 
pack, method, 670 
plunges in morning, 666 
sponging, 663, 665 
Colds, atropin for aborting, 254 
causes of, 198 
ointment for, formula, 518 
tonic prescription for, 203 



INDEX 



8 47 



Colic, intestinal, atropine in, 253 

lead, treatment, 735 

pains, morphine in, 268 

renal and hepatic, chloroform in, 307 
Collapse from broken compensation in 

valvular lesions, ergot in, 235 
Collargol, 148 
Collodia, definition, 23 
Collodion, 64 

as emollient, 130 

definition, 23 
Collodium, 64 

cantharidatum, 61, 64 

flexible, 65 
Colocynth as irritant purgative, 171, 
172 Color of feces, drugs which change, 

44 of urine, drugs which change, 44 
Coma, 743 

diabetic, 744 

drug, 744 

from carbonic oxide gas, 744 

from opium, diagnosis, 265 

from sunstroke, 744 

lumbar puncture in, 571 

uremic, 744 
Compensation, broken, in aortic sten- 
osis, digitalis in, 222 
Complement fixation test, gonorrheal, 

549 
Compound cathartic pill, 71 

as irritant purgative, 172 
effervescing powder, 49, 88 
jalap powder, 74 
licorice powder, 70, 93, 162 
pills of rhubarb, 50, 91, 164 
powder of ipecac, 74 
of rhubarb, 91, 165 
solution of iodine, 73 
spirit of juniper, 79 
tincture of cinchona, 357 
of gentian, as appetizer, 149 
of lavender, 79 
Compresses, cold, 665 
Concentration of blood in gassing, 

death due to, 749 
Congestion, acute, in tonsils and 
pharynx, suprarenal sprays to 
control, 470, 471 
of kidneys, 189 
Constipation, diet for, 613 
opium as cause of, 262 
treatment, 160, 613 
Contagion, direct, in 
Contagious disease, bathing in, 114 
carriers in, in 
disinfection in, no 
droplet method of transmission in, 

in 
flies in, 112 
how spread, in 
infected mosquitoes in, 112 
missed cases in, in 



Convulsions, causes, 768 
chloral in, 279 
due to epilepsy, 768, 770 

to inflammation of meninges, 768 
770 
of young children, 768 
paraldehyde in, 281 
puerperal, thyroid extract in, 437 

veratrum viride in, 214 
spasmophilic type, 768, 769 

treatment, 770 
uremic, raw kidney extracts in, 
508 

thyroid extract in, 438 
Copper sulphate, 66 
as emetic, 156 
as escharotic, 139 
Corpus luteum, 473 

administration, 477 

and menstruation, relation of 

mammary gland to, 475 
and ovaries, relation of, to mam- 
mary cancer, 475 
description, 473 
extract, 477 
function, 473 

in amenorrhea, 475, 476, 477 
in delayed menstruation, 475, 476, 

477 
in dysmenorrhea, 477 
in high blood-pressure, 476 

of menopause, 477 
in overweight with amenorrhea, 

476 
in pelvic pain from menstrual 

disturbances, 476 
in vomiting of pregnancy, 474, 

477 
of pregnancy, 474 ■ 

relation of, to vomiting of 
pregnancy, 474, 477 
relation of, to menstruation, 473 
uses, 475 
Corrosive mercuric chloride, poison 
tablet of, 
sublimate, 71, 340 
action, 340 
description, 340 
over-action, 342 
poisoning, 342, 761 
symptoms, 762 
treatment, 762 
toxic action, 342 
uses, 342 
Cotarninae hydrochloridum, 65 
Cotarnine hydrochloride, 65 
Cotton mill industries, death-rate in, 

732 
Cottonseed oil, 79 

Cough, whooping. See Whooping- 
cough. 
Coughs, causes of, 198, 199 



s 4 s 



INDEX 



Coughs due to dry mucous membranes, 
200 
to profuse secretion of mucous 
membranes, 200 
kinds, 199, 200 
treatment, 200 
troublesome, codeine in, 270 

Council on Pharmacy and Chemistry 
of American Medical Association, 3 1 

Counterirritants, 106 
official, 133 

Counterirritation, 132 
cautery for, 136 
drugs used for, 106 
treatment by, base of, 136 

Cream, fat content of, 597 
of tartar, 86 

Crede's method in ophthalmia neona- 
torum, 147, 148 

Creosote, 65 

Creosotum, 65 

Cresol, 65 

as antiseptic, 119 
as germicide, 122 

Creta praeparata, 65, 353 
as antacid, 153 

Cretin, thyroid dosage for, 434 

Cretinism, 430 
symptoms, 433 

Crile's method of conductive anes- 
thesia, 287 

Croton oil, 81 

as irritant purgative, 171, 172 

Croup, drugs used to relax spasm in, 
206 
medicated inhalations in, 514 

Crude calcium sulphide, 59 

Cubeba, 66 

Cubebs, 66 

Cumulative effects of drugs, 42 

Cupping, dry, for producing local 
hyperemia, 633 
wet, 537 

Cupri sulphas, 66 

Curative and protective serums, 564 
vaccines, 557 

Current, d' Arsonval, 646 
Franklinic, 648 
high frequency, 646 
Oudin, 646 
Tesla, 646 

Cushing's method in trigeminal neur- 
algia, 242 

Cutaneous test for protein idiosyn- 
crasy, 554 

Cystoscopic examinations, 532 

d'Arsonval current, 646 
Dakin's solution as antiseptic, 118 
Dancing as exercise, 686 
Dandruff, antiseptic wash for, 794 
Danger of partial anesthesia, 286 



Deadly nightshade, 55 
Death due to anesthesia, 286 
on operating table, causes, 286 
signs of, 743 
sudden, 743 
Death-rate in cotton mill industries, 

732 
Decimal system in prescription writing, 

26, 27 
Decocta, definition, 23 
Decoctions, definition, 23 
Digitalis, fluidextract of, 67 
Delirium tremens, 711 
digitalis in, 225 
ergot in, 234, 714, 715 
hypnotics in, 714 
lumbar puncture in, 716 
relation of cerebrospinal fluid to, 

716 
treatment, 713 
Delsarte system of physical culture, 

686 
Demulcents, 141 
Denatured alcohol, 238 
Deodorized opium, 82 

tincture of opium, 82 
Depressants, cerebrospinal, 258 
Depression following anesthesia, supra- 
renal extract in, 468 
Depresso-motors, 257 
Dermatol, 57, 155 

as dusting powder, 127 
Desensitizing a patient to protein 

poisoning, 553 
Desiccated hypophysis, J2> 
pituitary body, 73 
suprarenal glands, 97, 471 
thyroid gland, 432 
Dextri-maltose in intestinal putre- 
faction, 175 
Mead's, 175 
Dextrose, 594 

in intestinal putrefaction, 175 
Diabetes insipidus, ergot in, 235 

post-pituitary extract in, 448, 

mellitus, diet in, 624 

relation of pancreas to, 504 
Diabetic coma, 744 

flours, 627 
Diacetylmorphinae hydrochloridum, 66 

261 
Diacetylmorphine, 66 

hydrochloride, 66 
Diachylon plaster, 732 
Diaphoretics, 107, 183 
Diarrhea, acute, 381 

morphine in, 269 
Diastase, 66 
Diastasum, 66 
Diathermy, 647 
Diathesis, lymphatic, 498 



INDEX 



849 



Dichloramine-T as antiseptic, 118 
Diet, 611 

Allen- Joslin in diabetes, 624 

general, considerations, 607 

in anemia, 621 

in beriberi, 630 

in constipation, 613 

in diabetes mellitus, 624 

in dyspepsia, 613 

in fever, 328, 619 

in heart disease, 622 

in hypertension, 623 

in obesity, 627 

in pellagra, 631 

in pregnancy, 623 

in rickets, 630 

in scurvy, 629 

in tuberculosis, 624 

in xerophthalmia, 631 

Karell, in heart disease, 622 

purin-free, 586 

salt-free, 622 
Diethylbarbituric acid, 282 
Digestants, 150 
Digestion, drugs used to aid, 106 

of fats, 596 

of proteins, 580 
Digestive disturbances thyroid extract 

in, 438 
Digitalin, 217 
Digitalis, 66 

action, 218 

on circulation, 210 

administration, 217 

as diuretic, 190 

contraindications for, 223 

in aortic insufficiency, 222 

in auricular fibrillation, 224 

in broken compensation in aortic 
stenosis, 222 

in chronic myocarditis, 223 

in delirium tremens, 225 

in dropsical conditions, 225 

in heart weaknesses, 223 

in hemorrhage, 225 

in impotence in male, 225 

in menstruation, 225 

in mitral regurgitation, 221 
stenosis, 222 

in pneumonia, 224 

in tachycardia of hyperthyroidism, 
224 

infusion of, 67 

over-action, 220 

poisoning, treatment, 220 

tincture of, 67 

to strengthen heart, 217 

toxic action, 220 

uses, 221 
Digitoxin, 217 
Dihydrobromide of quinine in Graves' 

disease, 368 
54 



Diluted hydrochloric acid, 47 

muriatic acid, 47 

phosphoric acid, 48 
Dionin, 261 

Diphtheria, antitoxin treatment of, 
566 

immunizing dose for child, 567 

medicated inhalations in, 514 

prevention of, 566 

susceptibility to, Schick test in, 566 

treatment of, 566 
Dissaccharids, 593 
Disease, caisson, 750 

invasion of, body protections 
against, 548 
Diseased conditions, exercises for, 689 
Diseases, reportable, 817 
Disinfectants, no 
Disinfection, no 

drugs used for, 105 

formaldehyde for, 114 

in contagious disease, no 

of clothing, 113 

of excreta, 113 

of feces, 113 

of furniture, 114 

of hands, 113 

of room, 114 

of urine, 113 

paraformaldehyde in, 116 

sulphur for, 114 
Distilled extract of witch-hazel, 53 

water, 602 

to prevent salt deposits, 707 
Disturbances, simple, of surface of 

body, treatment of, 776 
Diuretic drink, formula for, 86 
Diuretics, 188 
Diuretin, 98 

as diuretic, 190 
Do and dont's of prescription writing, 

37 
DobelPs solution as gargle, 523 
Donovan's solution, 53 
Dosage, computing according to age, 
rule for, 38 
to weight, 38 
conditions which modify, 37 
in prescription writing, 37 
modified by abnormal physiology, 

39 

by frequency of dose, 40 

by pathologic condition present, 

39 . . 

rapidity of absorption in, 45 
Douches, 673 
hot air, 634 
nasal, 519 
vaginal, 532 

solutions for, 799 
yeast in, 510 
Dover's powder, 74, 82, 203, 260 



8 5 o 



INDEX 



Dressings, removal of, partial anes- 
thesia for, 302 

Dried alum, 51 

antidiphtheric serum, 564 
antitetanic serum, 565 
thyroid glands, 99 

Drop dosage in prescription writing, 35 

Droplet method of transmission of 
contagious disease, in 

Dropsical conditions, digitalis in, 225 

Drowning, treatment, 751 

Drug addicts, regulated treatment of, 

? 2 3 . . - 

treatment at Riverside Hospital, 
N. Y., 724 

anaphylaxis, 42 

aphorisms, 803 

comas, 744 

fallacies, 805 
Drugs, absorption of, rapidity of, 44 

action of, condition of stomach 
modifying, 40 
conditions modifying, 40 
idiosyncrasy modifying, 41 
intolerance modifying, 41 
tolerance modifying, 42 

administration of, 44 
capsules for, 34 

against which there is an idiosyn- 
crasy, 42 

and preparations, official, 21 

causing eruptions on skin, 43 
erythema of skin, 776 

cumulative effects of, 42 

disguising of, in prescriptions, 32 

five most useful, 803 

for nursing mothers, 43 

for office dispensing, 812 

in fever, 331 

incompatibility of, 36 

intravenous administration of, 542 

poisoning by, 42 

acute, aims of treatment, 758 

treatment, 757 
chronic, 43, 711 

stock-mixtures, unscientific, 30 

synonyms, 101-104 

that are specific, 109, 338, 371 

that change color of urine, 44 

that color feces, 44 

therapeutic classification of, 105 
•truths about, 800 

use of, in disease, 29 
restrictions in, 30 
Drugs used as emetics, 106 
as specifics, 109, 338, 371 
externally for action on skin, 106, 

125 
for action on central nervous 
system, 108, 247 
on circulation, 108, 207 
on genitourinary system, 187 



Drugs used for action on mucous mem- 
branes, 106, 140 
on respiratory tract, 108, 198 
for counterirritation, 106 
for general anesthesia, 109, 284 
for hyperemia, 106 
for local action in intestinal canal, 
106, 157 
in stomach, 106, 148 
anesthesia, 109, 316 
for producing sleep, 108, 270 
for systemic action, 107 
for vomiting, 106 
internally for action on skin, 107, 

183 
locally, 105 

to accelerate heart, 108, 211 
to aid digestion, 106 
to allay irritation of mucous 
membranes, 106 
of skin, 106 
to blister, 106 
to contract blood-vessels, 108, 231 

uterus, 108 
to decrease perspiration, 107, 186 
secretion of mucous membranes 
205 _ 
of respiratory tract, 108 
to depress brain and spinal cord, 
108, 257 
heart, 108, 212 
to destroy microorganisms, 105, 
no 
skin parasites, 105 
tissue, 106 
to dilate blood-vessels, 108, 235 
to diminish intestinal putre- 
faction, 107, 173 
to disinfect, 105 
to evacuate bowels, 107 
to increase amount of urine, 107, 
188 
appetite, 106, 148 
excretion of uric acid, 398 
menstruation, 107 
peristalsis, 106 
perspiration, 107, 183 
secretion of mucous membranes 
201 
of respiratory tract, 180 
to inhibit growth of bacteria in 
kidneys and bladder, 107, 

193 
on body, 105 
secretion of mucous mem- 
branes, 106 
to lower temperature of body, 

109, 325 
to modify metabolism, 109, 382 
to reduce acidity, 106 
to relax spasm, 206 

of respiratory tract, 108 



INDEX 



851 



Drugs used to relieve irritation in stom- 
ach, 106, 153 
to remove intestinal parasites, 107 
to render urine acid, 107, 192 

alkaline, 107, 190 
to stimulate activity of skin, 
107, 183 
brain and spinal cord, 108, 248 
metabolism, 388 
mucous membranes, 106 

of genitourinary system, 
107, 195 
to stop acute pain, 108, 259 
to strengthen heart, 108, 214 
valuable, action and uses of, 109 
Dry cupping for producing local 
hyperemia, 633 
heat, value of, 134 
Dusting powders, 126 

conditions in which used, 126 
official, 126 
Dye-stuffs, poisoning from, 740 
Dysentery, amebic, anthelmintics for, 
181 
treatment, 181 
bacillary, treatment of, 569 
Dysmenorrhea, 196 
corpus luteum in, 477 
nitroglycerin in, 247 
Dyspepsia, diet in, 613 
Dyspnea, chronic, oxygen inhalations 

in, 513 
Dysthyroidism, 418 
Dystrophy adiposogeni talis, 453 

anterior pituitary extract in, 454 

Ear, middle, inflammation of, 797 
Eclampsia. See also Convulsions. 

of uremia, thyroid extract in, 438 

puerperal, thyroid extract in, 437 
veratrum viride in, 214 
Eczema, 782 

of children, 782 

thyroid preparation for, 434 
Edema, angioneurotic, 780 

of brain, ergot in, 233 
Effervescent potassium nitrate, 87 

sodium phosphate, 94 
Effervescing citrated caffeine, 58 

powder, compound, 88 

waters for administering drugs, 32 
EfHeurage, 675 
Eggs, 590 

calories in, 591 

digestion of, 590 
Elaterin, 67 
Elaterinum, 67 

Elaterium as irritant purgative, 171 
Electric light baths, 662 
Electricity, 638 

faradic, in opium poisoning, 266 

general considerations, 639 



Electricity, static, 648 
Electrocautery for counterirritation, 

136 
Electrolysis, 644 
Electrotonus, 641 
Elixir aromaticum, 67 
glycyrrhizae, 67 
of calisaya, 63 
Elixirs, definition, 23 
Emaciation in Graves' disease, 419 
Emergencies, treatment of, 743 
Emetic, tartar, 52 
Emetics, 106, 156 

Emetinae hydrochloridum, 68, 203 
Emetine and ipecac for amebic 
dysentery, 181 
bismuth iodide as anthelmintic, 182 

in amebic dysentery, 182 
caution in use of, 182 
hydrochloride, 68, 203 
as anthelmintic, 182 
Emmenagogues, 107, 195 
Emollients, 128 

indications for use of, 129 
official, 129 
liquid, 130 
Emphysema, climate for, 705 
Emplastra, definition, 23 
Emplastrum belladonnae, 55 
plumbi, 732 
resinae, 732 
Emulsa, definition, 23 
Emulsions, definition, 23 
Endermal method of vaccination, 558 
Endocrine disturbances, relation to 
insanity, 403 
types, 400 
glands, 399 

disturbances, list, 405 

function of, lines of investigation, 

400 
general considerations, 399 
having positive therapeutic value, 

406 
preparations of, 399 
relation to protein poisoning, 552 
Enema, 526 
alcohol, 606 
calcium, 606 
glucose, 605, 606 
glycerin, 159 
habit, 161 
nutrient, 605 

in vomiting of pregnancy, 605 
of physiologic saline solution after 

operation, 298 
turpentine, 158 
English in prescription writing, 25 
Enteroclysis, 527, 543 
indications for, 527 
saline solution in, 543 
solutions for, 529 



852 



INDEX 



Enuresis, nocturnal, thyroid prepara- 
tion for, 436 
Epilepsy, bromides in, 275 
convulsions due to, 768, 770 
nitrites in, 246 
thymus gland in, 404 
thyroid extract in, 438 
Wassermann test in, 347 
whole pituitary gland extract for, 
456 
Epinephrine, 459 
action of, 459 
before intravenous injection of 

arsphenamine, 470 
in asthma, 469 

in cocaine for local anesthesia, 471 
in infiltration anesthesia, 319 
injection before arsphenamine injec- 
tion, 349 
intraspinally, in shock conditions, 

470 
over-action of, treatment, 467 
preparations, 472 

action on circulation, 211 
solutions in morphine and opium 
poisoning, 470 
Epiphysis cerebri, 500 
Epistaxis, specifics in, 369 
Epithelioma, radium in, 656 
Epsom salt, 76 

as saline purgative, 169, 170 
disguising of, in prescriptions, 
32 
Equivalents, table for, for prescription 

writing, 29 
Ergot, 68 
action, 232 

on circulation, 211 
on uterus, 233, 234 
administration, 232 
as oxytocic, 197 
as specific in uterine hemorrhage, 

369 
as vasoconstrictor, 232 
extract of, 68 
fluidextract of, 68 
for intestinal paresis, 158 
for promoting intestinal peristalsis, 

2 34 
in acute cerebrospinal inflammation, 

233 
meningitis, 234 
collapse from broken compen- 
sation in valvular lesions, 235 

in asthma, 235 

in delirium tremens, 234, 714, 715 

in depressed conditions, 235 

in diabetes insipidus, 235 

in heart failure, 234 

in hyperthyroidism, 235 

in internal hemorrhage, 235 

in menstruation, 197 



Ergot, in shock conditions, 234 

intramuscular injection of, 234 

of rye, 68, 232 

over-action, 233 

poisoning, 233 
treatment, 233 

toxic action, 233 

uses, 233 
Ergota, 68 
Ergotine, 68, 232 
Ergotinine, 232 
Ergotism, 233 
Ergotoxine, 232 

Eruptions on skin, drugs causing, 43 
Erythema of skin, drugs that cause, 

776 
Erythrol tetranitrate, 245 
Erythroxylon, 321 

coca, 64 
Escharotics, 106, 138 
Eserine for contraction of pupils, 255, 
256 

salicylate, 85, 256 
Ether, 50 

action, 309 _ 

administration, 309 

anesthesia, 309 

contraindications, 312 
death rate in, 288 
drop method in, 313 
paralytic stage of, 311 

toxic action, 311 

uses, 312 
Ethical suggestions to young prac- 
titioner, 831 
Ethics, medical, principles of, of 

American Medical Association, 819- 

831 
Ethyl alcohol, 238 

chloride, 50 

as local anesthetic, 325 
Eucaine chloride, 56 
Eucalyptol, 68 
Eucalyptus globulus, 68 

oil, 79 
Eunuchism, 489 
Evolution of a prescription, 32 
Excessive perspiration, 796 
Excreta, disinfection of, 113 
Excretion of dose, dosage modified by, 

40 
Exercises, active, 680 

breathing, value of, 513 

for adults, 686 

for children, 684 

for diseased conditions, 689 

for youth, 685 

passive, 680 

physical, 680 

general considerations, 680 

Swedish system, 683 

Zander methods of, 683 



INDEX 



853 



Exophthalmic goiter. See Graves' 

disease. 
Exophthalmos in Graves' disease, 

cause, 424 
Expectorants, 108, 201 
Exsiccated sodium phosphate, 94 
External bleeding, styptics for, 369 
Extirpation of tonsils, effects of, 403 
Extract, definition, 23 

Goulard's, 86, 732 

of cascara sagrada, 62 

of ergot, 68, 232 

of licorice, 70 

of opium, 82, 260 
powdered, 82 

of oxgall, powdered, 68 

of rhubarb, 90 

of witch-hazel distilled, 53 
Extracta, definition, 23 
Extractum cascarae sagradae, 62 

ergotae, 68, 232 

fellis bovis, 68 

glycyrrhizae, 70 

opii, 82, 260 

rhei, 90 
Extremities, faradization of, 645 
Eye, burns of, 756 

inflammations, atropine in, 255 

pain, hot fomentations for, 669 

Facial massage, 678 

Fallacies, drug, 805 

Faradic electricity in opium poisoning, 

266 
Faradism, 644 

for hysterical pain, 645 

to cause contractions of stomach and 
intestines, 645 
Faradization of extremities, 645 
Fat, 596 

content of foods, 597 
of milk, 589 

digestion of, 596 

wool, 50 
hydrous, 50 
Fat-soluble vitamines, 583 
Feces, disinfection of, 113 

drugs which color, 44 
Feeding, forced, 524 
in rest cure, 694 

rectal. See Enema. 
Feet, sweating of, 796 
Fel bovis, 68 
Fermented milks, 589 
Ferri carbonas saccharatus, 68, 394 

hydroxidum cum magnesii oxido, 
69, 386 

phosphas, 395 

sulphas, 69, 395 
Ferric chloride, tincture of, 395 

hydroxide with magnesium oxide, 
386 



Ferrous carbonate, 69 

iodide, syrup of, 395 

phosphate, 69 

sulphate, 69, 395 
Ferrum, 68 

reductum, 69, 395 
Fever, antipyretics in, 330 

carbohydrate foods in, 328, 329 

care of bowels in, 329 
of mouth in, 330 

causes, 326 

crisis in, 326 

definition, 325 

diet in, 328, 619 

drugs in, 331 

high, cold applications in, 663 
nitroglycerine in, 243, 247 

malarial, specific treatment of, 362 

reduction by lysis, 326 

of temperature in, 327, 328, 

329 

temperature in, point at which to 
combat, 331 
taking in, 332 

types, 326 

typhoid, twenty-four hour diet for, 
620 

urine in, 332 

value of, in fighting protein intoxi- 
cation, 326 

water in, 329 
Fibrillation, auricular, digitalis in, 

224 
Fish, 1 pound, calories in, 591 
Flatulence, aromatic spirits of am- 
monia for, 152 
Flaxseed, oil of, 79 

Flies in spread of contagious disease, 
112 

solution to attract and kill, 781 

Spanish, 61 
Flour, diabetic, 627 

paste foods, 592 
Flowers of sulphur, 97 
Fluid in abdomen, removal of, 536 

in chest, removal of, 536 
Fluidextract, definition, 23 

of aspidosperma, 55 

of buchu, 58 

of cascara sagrada, 62, 163 
aromatic, 62 

of digitalis, 67 

of ergot, 68, 232 

of gelsemium, 258 

of ipecac, 74 

of pilocarpus, 85 

of pomegranate, 70 

of rhubarb, 90 

of senna, 92, 165 

of spigelia, 95 

of squill, 92 

of veratrum viride, 99 



854 



INDEX 



Fluidextractum aspidospermatis, 55 

buchu, 58 

cascaras sagradae, 62, 163 
aromaticum, 62 

digitalis, 67 

ergotag, 68, 232 

gelsemii, 258 

granati, 70 

ipecacuanhas, 74 

pilocarpi, 85 

rhei, 90 

scillae, 92 

sennas, 92, 165 

spigelian, 95 _ 

veratri viridis, 99 
Focal infections in insanity, 403 

of mouth, danger of, 617 
Fomentations, hot water, 135 
Food, 576 

alcohol as substitute for, 239, 242 

flour, paste, 592 

general discussion, 576 

nitrogenous, 579 

temperature of, 609 

that causes irritations of skin, 776 
Foot bath, 671 

Football, injurious effects of, 689 
Forced feeding, 524 

in rest cure, 694 
Fordyce treatment of syphilis, 345 
Formaldehyde, 115 

action of, 115 

fumigation, 114 

poisoning, treatment of, 115 

solution of, 75, 115 

toxic action of, 115 

uses, 116 
Formalin, n D 
Formulary, National, 21 
Fowler's solution, 54, 382 
Foxglove, 66, 217 
Fractures, massage after, 678 
Franklinic current, 648 
Freezing, 773 
Friction, 675 

with cold sponging, 663 
Frohlich's syndrome, 453 
Frostbite, 773 
Fructose, 594 
Fruits, 602 

laxative, 603, 614 
Fuller's earth as dusting powder, 128 
Fumigation, no 

formaldehyde, 114 

sulphur for, 114 
Furniture, disinfection of, 114 
Furuncle, phenol liquef actum for, 122 

Galactose, 598 
Galvanism, 640 

dangers of, 642 

for nutritional effect, 642 



Galvanism, to affect nervous system, 
642 

to excite a muscle, 641 

to stimulate phrenic nerve, 642 
Gargles, 521, 522 
Gargling, 520 

astringent solution for, 522 

solutions for, 521, 522 
Gas, illuminating, poisoning, 745 
treatment, 747 

laughing, 313 

mustard, poisoning, 748 

phosgene, poisoning, 749 

war, poisoning from, 748 
Gassing, venesection after, 749 
Gastric hyperacidity, 615 

indigestion, treatment, 150 

lavage, 524 

contraindications, 526 
indications for, 525 
Gastritis, 149 

Gastrointestinal tract, action of al- 
cohol on, 239 
Gavage, 524 

Gelatin in hemorrhage, 371 
Gelsemine to dilate pupil, 259 
Gelsemium, action, 258 

administration, 258 

as cerebrospinal depressant, 258 

over-action, 259 

poisoning, treatment, 259 

toxic action, 259 

uses, 259 
General anesthesia, drugs used to 
cause, 284, 285. See also Anes- 
thesia, general. 

physical measures, 632 
Genitalia, development of, relation of 
thymus gland to, 498 
suprarenal gland extract in, 46.7 
Genito-urinary system, drugs used for 

action on, 107, 187 
Gentian, compound tincture of, as 
appetizer, 149 

violet as antiseptic, 119 
Germicides, 105 
Giant urticaria, 780 
Giantism, 450 
Gin, alcohol content of, 596 
Glacial acetic acid, 47 

as escharotic, 138 
Glauber's salt, 95 

as saline purgative, 169, 170 
Glucose, 69, 594 

in intestinal putreafction, 175 

solutions for enema, 605, 606 
to prevent acidosis, 605 
Glucosum, 69 
Glusidum, 56 
Gluten flours, 627 
Glycerin, 69 

enema, 159 



INDEX 



855 



Glycerin suppositories, 69 
Glycerinum, 69 
Glycerita, definition, 23 
Glycerite of boroglycerin, 47 

of phenol, 48, 144 

of tannic acid, 84, 119 
Glyceritum acidi tannici, 48, 144 

boroglycerini, 47 

phenolis, 84, 119 
Glycerophosphates, 598 
Glycosuria and posterior lobe of 
pituitary gland, 447 

relation of pancreas to, 504 
to suprarenals, 459 
Glycyrrhiza as laxative, 162 
Goetsch's test in thyroid disease, 422 
Goiter, emaciation in, 419 

from drinking water, 417 

from hard water, 708 

in young girls, iodine in prevention, 
416 

intra-thoracic, 417 

pregnancy and, 417 
Golf as exercise, 686 
Gonorrhea in male, prevention, 530 

treatment of, 563 

vaccination in, 563 
Gonorrheal complement fixation test, 

549 
Goose flesh, 663 
Goulard's extract, 86, 732 
Gout, acute, cinchophen for, 398 

cincEophen in, 373 

climate for, 705 

colchicum in, 371 
Gram, 28 
Granatum, 70 
Granulated opium, 82 
Grape sugar, 594 
Graves' disease, basal metabolism in, 

425 
carbohydrate tolerance in, 409 
dihydrobromide of quinine in, 368 
disturbances of, 424 
exophthalmos in, cause, 424 
operation in, 427, 428 
pregnancy in, 417 
prevention in, 426 
serums in, 428 
surgical mortality in, 429 
thymus gland extracts in, 500 
thyroxin in, 425 
treatment, 426 

s-ray ' treatment of thyroid in, 
427 
Green hellebore, 99 
Gregory's powder, 91, 165 
Growth, anterior pituitary gland in, 
4So 
in endocrine disturbances, 402 
of bacteria in kidneys and bladder 
drugs used to prevent, 107, 193 



Growth of bacteria on body, drugs 
used to inhibit, 105 

relation of thymus gland to, 494, 496 
Gum arabic, 46 

Benjamin, 56 
Gwathmey's rectal anesthesia, 290, 291 

Habit, bromide, symptoms, 273 
treatment, 274 
chloral, 277 
cocaine, 323, 722 
treatment, 324 
morphine, 716 

atropine as antidote in, 718, 721 
symptoms from withdrawal of 

drug, 719 
treatment, 719 
paraldehyde, 280 
sulphonal, 282 
tobacco, 725 
trional, 282 
veronal, 283 
Hair, care of, 794 

in endocrine disturbances, 401 
Halazone as antiseptic, 118 
Handbag, always-ready, 810 
Hands, chapped, 783 
disinfection of, 113 
Hard water, goiter from, 708 
Harrison Narcotic Law, 815 
Hashish, 61 

Hay-fever, change of climate in, 704 
prevention of, 561 
suprarenal sprays in, 470 
vaccination in, 561 
Head lice, 793 
Headache, massage for, 678 

pituitary, whole gland extract in, 

454 
puncture, 571 

relation to endocrine secretions, 403 
thyroid preparation for, 435 
Health, departments of, and medical 
laws, 815 
resorts, altitude of, 700 
of Atlantic coast, 702 
of lake regions, 702 
of southern California, 702 
State department of, 818 
Heart, action of opium on, 262 
of tobacco on, 729 
atropin to stimulate, 252, 254 
disease, diet in, 622 
drugs used to accelerate, 108, 211 
to depress, 108, 212 
to strengthen, 108, 214 
failure, ergot in, 234 

sudden, strophanthus in, 227 
strychnine in, 231 
reserve strength of, lack of, reasons, 

208 
weaknesses, digitalis in, 223 



S$6 



INDEX 



Heat applications for promoting 
peristalsis, 158 
in presence of pus, 668 
dry, value of, 134 
for systemic effect, 658 
in congestion of kidneys, 189 
moist, applications, 668, 669 
prostration, 773 
stroke, 773 

Height and age, weight for, table of, 

39 
Heliotherapy, 634 

conditions benefited by, 636 

dosage, 636 

exposures in, 635 

in tuberculosis, 636 
Hellebore, American, 99, 213 

green, 99, 213 
Hematemesis, specifics in, 369 
Hemianopsia, transient bi-temporal, 

from enlarged pituitary gland, 

• 449 
Hemophilia, brain extracts in, 509 
Hemoptysis, morphine after, 269 

specifics in, 369 
Hemorrhage, coagulose in, 371 

gelatin in, 371 

internal digitalis in, 2 25 
ergot in, 235 

intestinal, specifics in, 370 

kidney, specifics in, 3 70 

nitroglycerin in, 225, 369 

of menopause, thyroid extract for, 

439 
serums as specifics in, 369 
thromboplastin solutions in, 371 
uterine, ergot in, 369 
ice for, 670 
Hemorrhoids, ice to rectum and anus 

for, 670 
Hemp, Indian, 61 
Hepatic and renal colic, chloroform in, 

3°7 
colic, morphine in, 268 
Heraeus quartz lamp for heliotherapy, 

637 
Heredity in immunity, 547 
Heroin, 66, 261 

poisoning, 718 
Hertz waves, 635 ^ 
Hexamethylenamina, 70 

to render urine acid, 193 
Hexamethylenamine, _ 70 

as urinary antiseptic, 194 

preparations as gargles, 523 
Hexamethylene-tetramine, 70 
Hiccough in anesthesia, 298 
High frequency currents, 646 
Hippocrates, oath of, 830 
Histamine, 232, 448 
Histories, clinical, 807 
Hoffmann's drops, 309 



Holocaine hydrochloride, as anes- 
thetic, 324 
Homatropinae hydrobromidum, 256 
Homatropine, hydrobromide of, 71 

to paralyze accommodation in eye 
tests, 255 
Honeys, definition, 24 
Hook-worms, 175 

anthelmintics for, 1 79 

treatment, 179 
Hordeolum, 786 
Hot air douche, 634 

hyperemia by means of, 633 

applications to abdomen, 669 

baths, effects of, 657, 658 

fomentations for eye pain, 669 

foot bath for sprained ankle, 669 

moist applications to throat, 669 

sitz bath, 671 

springs, 708 

water fomentations, 135 
Hunger sensations, 577 
Huxham's tincture, 357 
Hydrargyri chloridum corrosivum, 71 
mite, 71 

iodidum flavum, 71 
rubrum, 72 

oxidum flavum, 72, 339 
rubrum, 72, 339 

salicylas, 72, 340 
Hydrargyrum, 71 

ammoniatum, 72, 340 
Hydrastinae hydrochloridum, 72 
Hydrastine hydrochloride, 72 
Hydrastininae hydrochloridum, 73 
Hydrastinine hydrochloride, 73 

as oxytocic, 198 
Hydra ted chloral, 276 
Hydrobromide of homatropine, 71, 256 
Hydrochloric acid as aid to digestion, 

151 
diluted, 47 

for postoperative vomiting, 299 
importance of, 506 
Hydrochloride of apomorphine action, 

157 
administration, 157 
uses, 157 
of cocaine, 64 
Hydrofluoric acid poisoning, 731 
Hydrogen dioxide, 122 
action of, 123 
in sterilization, 122 
solution as gargle, 522 
uses, 123 
Hydrophobia, Pasteur protective in- 
oculations in, 564 
Hydrotherapy, 656 

for local effect, 667 
Hydrous wool fat, 50 
Hyoscine, 249 
hydrobromide, 92, 249, 283 



INDEX 



857 



Hyoscyaminae hydrobromidum, 249 
Hyoscyamine, 249 

Hyoscyamus as cerebral stimulant, 249 
Hyperacidity, gastric, 615 

treatment, 152 
Hyperadrenalism, 461 
Hyperemia, drugs used to cause, 106 

local, 632. See also Bier's hyperemic 
treatment. 

object, 632 
Hyperemic treatment, 632 
Hyperidrosis, localized, 796 
Hypersecretion of pituitary gland, 450, 

452 
Hypersensibility, 550 
Hypertension, diet in, 623 

prevention of, 237 

systolic, causes, 236 

treatment, 237 
Hyperthyroidism, 418 

administration of, anesthetic in, 293 

calcium in, 409 

ergot in, 235 

symptoms, 420 

tachycardia of, digitalis in, 224 
Hypnotics, 108, 270 
Hypoadrenalism, 463 
Hypodermatic medication, 533 
Hypodermic case, 810 

injection, endermic method, 535 
intramuscularly, drugs best for, 

535 

syringe, proper method of using, 534 
Hypodermoclysis, 542 
Hypophysis cerebri, 445. See also Pi- 
tuitary gland. 

desiccated, 73 

sicca, 73, 457 
Hyposecretion of thyroid gland, 430 
Hypothyroidism, 418 
Hysterectomy, age for, 482 

ovarian extracts in, 483 
Hysteria, 697 

cerebral stimulants in, 248 

rest cure in, 698 
Hysterical patients, anesthetic for, 289 

Ice bag, 670 

for uterine hemorrhage, 670 

to anus and rectum for hemorrhoids, 
670 

to perineum, 670 
Ichthalbin as emollient, 132 
Ichthyol as emollient, 130 

for external use, 131 

for internal use, 131 
Idiocy, hyposecretion of thymus gland 

in, 497 
Idiosyncrasy, drugs frequently pro- 
ducing, 42 

modifying action of drugs, 41 

protein, cutaneous test for, 554 



Illuminating gas poisoning, 745 

treatment, 747 
Immunity, 547 

acquired, 547 

antibodies in, 549 

heredity in, 547 

natural, 547 

permanent, diseases which render, 
547 
Impetigo contagiosa, 786 
Impotence in male, digitalis in, 225 
testicle transplantation in, 491 
Incompatibility, chemical, 36 

of drugs, 36 

pharmacal, 36 

therapeutic, 36 
Indian hemp, 61 
Indigestion, 150, 612 

gastric, treatment, 150 

suprarenal gland extract in, 469 
Industrial poisoning, 731 
Infantile obesity, thyroid preparation 
for, 435 

paralysis, treatment, 574 

tetany due to parathyroid disturb- 
ance, 442 
Infantilism, anterior pituitary lobe in, 
452 

pineal gland in, 503 
Infants' food, alkalinization of, 589 

venesection in, 539 
Infected teeth and tonsils, removal of, 

before major operation, 287, 294 
Infections, acute, nuclein in, 510 

focal, of mouth, dangers of, 617 

venereal, prevention, 530 
Infiltration anesthesia, 316 

epinephrine in, 319 
Inflammation of kidneys, symptoms, 
187 

of middle ear, 797 
Infra-red rays, 635 
Infundibular extract in obstetrics, 

455 
Infusa, definition, 23 
Infusion of digitalis, 67 
Infusum digitalis, 67 
Ingrowing toe-nail, 797 
Inhalations, 513 

emergency apparatus for, 514 

for asthma, 516 

for laryngitis, 516 

for ozena, 515 

for whooping-cough, 516 

gauze mask for, 516 

medicated, 514 

oxygen, 315, 513 

tincture of benzoin, 515 
Inhaling tubes, pocket, 518 
Injection of saline solutions, intra- 
venous, 540 
Injections, urethral, 529 



s 5 s 



INDEX 



Inoculations, Pasteur protective, in 

hydrophobia, 564 
Insanity, relation to endocrine distur- 
bances, 403 

rest cure in, 698 
Insolation, 771 

treatment, 772 
Insomnia, chronic, chloral in, 279 
Insufficiency, aortic, digitalis in, 222 
Insufflation, 518 

powders for, 519 
Intercostal neuralgia, counterirritant 

application in, 137 
Intestinal bacteria, 616 

canal, drugs used for local action in, 
106, 157 

colic, atropine in, 253 

hemorrhage, specifics in, 370 

parasites, 175 

drugs used to remove, 107 

putrefaction, chronic poisoning 
from, 618 
drugs used to diminish, 107, 173 
Intestines, contractions of, faradism 

to cause, 645 
Intolerance modifying action of drugs, 

4 1 
Intoxication, protein, value of fever in 

fighting, 326 
Intradermal tests for tuberculosis, 563 
Intramuscular injections of mercury, 

Intrathoracic goiter, 417 
Intrauterine irrigation, 533 
Intravenous administration of drugs, 

54 2 . 
injection of saline solutions, 540 
indications for, 541 
method, 540 
solutions for, 540 
Inunctions, 132 
Invasion of disease, body protections 

against, 548 
Iodide of mercury, red, 72, 339 
yellow, 71, 339 
of potassium, 88 
of sodium, 94 
Iodides in syphilis, 346 
Iodine, 73 
action, 391 

as counterirritant, 135 
compound solution of, 73 
content of thyroid gland, 412 
in • prevention of goiter in young 

girls, 416 
in thyroid insufficiency, 409 
ointment of, 74 
over-action, 392 
poisoning, chronic, 392 

treatment, 392 
preparations, as dusting powders, 
127 



Iodine, tincture of, 73 
as antiseptic, 119 

to modify sclerosis, 393 

to stimulate metabolism, 389 

uses, 392 
Iodoform, 73, 119 

as dusting powder, 127 
Iodoformum, 73 
Iodum, 73 
Ionization, 643 
Ipecac, 74 

action, 203 

administration, 203 

and emetine for amebic dysentery, 
181 m 

and opium, powder of, 74, 82 

as emetic, 156 

as expectorant, 203 

compound powder of, 74 

fluidextract of, 74 

over-action, 204 

poisoning, treatment, 204 

syrup of, 74 

uses, 204 
Ipecacuanha, 74 
Iron, 68, 600. See also Ferri. 

action, 396 

administration of, 395 

in anemia, 397 

in chlorosis, 397 

over-action, 397 

Quevenne's, 69 

reduced, 69, 395 

springs, 709 

to stimulate metabolism, 394 

uses, 396 

waters, 709 
Irrigation, bladder, 531 
solutions for, 531 

intrauterine, 533 

vaginal, 532 
Irritability of bladder, atropine in, 

253 
Irritant purgatives, 107, 171 

definition, 158 
Irritation, 133 

of mucous membranes, drugs used to 

allay, 106 
of skin, drugs used to allay, 106 

foods causing, 776 
of stomach, drugs used to relieve, 
106 
Itch, 791 

barber's, 790 
Itching, 777 

treatment, 778 
Ivy poisoning, 781 

Jaborandi, 85 
Jalap, 74 

as irritant purgative, 171, 172 

powder, compound, 74 



INDEX 



859 



Jalapa, 74 

Jamestown weed, 95 

Jaundice, catarrhal, ammonium chlo- 
ride in, 203 

Jelly, petroleum, 84 
white, 84 

Joints, affections of, iodides in, 393 
inflamed, alcohol pack for, 241 
painful, counterirritant for, 137 

Juniper berries, oil of, 79 
spirit of, 79 
compound, 79 

Karell treatment in heart disease, 
622 

Katelectro tonus, 641 

Kefir, 589 

Kentish's ointment, 75 

Kephalin, 510 

Kidneys, 508 

congestion of, 189 

growth of bacteria in, drugs used to 

prevent, 107, 193 
hemorrhage, specifics in, 370 
inflammation of, symptoms, 187 
pelvis infection, salol in, 382 
raw, extracts from, in uremic con- 
vulsions, 508 

Knock-out drops, 276 

Kolmer and Yagle's conclusions con- 
cerning arsphenamine and neoars- 
phenamine, 349 

Koumys, 589 

Kumiss, 589 

Kyphosis, 450. 

Labarraque's solution, 60 
as antiseptic, 118 

Labor, painless, 319 

second stage of, chloroform in, 307 

Lactation, development of, 486, 487 
relation to amenorrhea period, 486 

Lactic acid bacilli in intestinal putre- 
faction, 173 

Lactose, 594 

in intestinal putrefaction, 175 

Lake regions, health resorts of, 702 

Lanolin, 50 
anhydrous, 50 

Laparotomy, bladder paralysis after, 
pituitary extract for, 456 

Lard, benzoinated, 49 

Larvae, amphibian, effects of endo- 
crine therapy on, 412 

Laryngitis, inhalation formula for, 516 

Lassar's paste in eczema, 783 

Latin in prescription writing, 25 

Laudanum, 82, 260 

Laughing gas, 313 

Lavage, gastric, 524 

contraindications, 526 
indications for, 525 



Lavender, compound tincture of, 79 

oil of, 79 
Law, medical and departments of 
health, 815 
narcotic, Harrison, 815 
prohibition, 815 
Laxative cereals, 614 
definition, 158 
fruits, 603, 614 
oils, 614 
vegetables, 614 
Laxatives, 107, 161 
Lead acetate, 85, 732 
colic, treatment, 735 
oxide, 732 
plaster, 732 
poisoning, 732 

acute, treatment of, 733 
chronic, 733 
symptoms, 734 
treatment, 736 
iodides in, 394 
nervous system in, 735 
subacetate, solution of, 86 
sugar of, 85, 732 
toxic action of, 732 
Lecithin, 598 
Leech, American, 537 
imported, 537 
method of applying, 537 
Swedish, 537 
Leeching, 537 

conditions in which used, 537 
Legumes, 593 
Leucorrhea, 799 
Leukemia, treatment, 182 
Levulose, 594 
Leydig, cells of, 490 
Lice, head, 793 
Licorice, 70 

as laxative, 162 
extract of, 70 

powder, compound, 70, 93, 162 
Life extension, 812 
Light, electric, baths, 662 

magnesia, 76 
Lime, 60 

chloride of, 60 
chlorinated, 60 
sulphurated, 59 
Ling system of physical culture, 683 
Liniment, chloroform, 75, 304 
of belladonna, 55 
of camphor, 74 
of soft soap, 75, 92 
soap, 75 
m soft, 75, 92 m m 
Linimenta, definition, 23 
Liniments, stimulating official, 133 
Linimentum calcis, 74, 353 
camphorse, 74 

as counterirritant, 133 



S6o 



INDEX 



Linimentum chloroformi, 75, 304 
saponis, 75 
mollis, 75, 92 

as counterirritant, 133 
terebinthinae, 75 
Linseed oil, 79 
Lipoid, brain, 510 
Lipoids, 597 
Liquefied carbolic acid, 84 

phenol, 84 
Liquid carbon dioxide as escharotic, 
140 
petroleum, 84 

table of, for prescription writing, 
28 
Liquor alumini acetatis as astringent, 

143 
subacetatis as astringent wash, 

143 
arseni et hydrargyri iodidi, 53 
calcis, 60, 352 

as antacid, 153 
cresolis compositus, 65 

in sterilization, 122 
definition, 23 

ferri subsulphatis, 130, 395 
formaldehydi, 75 

as antiseptic, 115 
hydrogenii dioxidi, 75 
as gargle, 522 
in sterilization, 122 
hypophysis, 457 
iodi compositus, 73 
magnesii citratis, 91 

as saline purgative, 169 
plumbi subacetatis, 86, 130, 732 

dilutus, 732 
potassii arsenitis, 54, 382 
sodae chlorinates, 60 
as antiseptic, 118 
Liter, 28 
Litharge, 732 
Lithium springs, 709 

waters, 709 
Liver, 507 

disturbances during arsenic treat- 
ment of syphilis, 350 
extracts, 507 
Local action of cold, 670 

anesthesia. See Anesthesia, local. 
effect, hydrotherapy for, 667 
hyperemia, 632. See also Bier's hy- 
per emic treatment. 
use, drugs for, 105 
Localized hyperidrosis, 796 
Locomotor ataxia, arsphenamine in, 

347 
Lubricant for massage, 674 
Luetin skin test in syphilis, 344 
Lugol's solution, 73 
Lumbar puncture, 569 

in cerebrospinal meningitis, 573 



Lumbar puncture, in coma, 571 

in delirium tremens, 716 

method, 572 

position for, 571 

shock following, 572 

Wassermann test for syphilis by, 
572 
Luminal, 283 
Luminal-sodium, 283 
Lunar caustic, 53, 147 

as escharotic, 139 
Luncheon, 608 
Lycopodium, 75 

as dusting powder, 128 
Lymph glands, 511 
Lymphatic diathesis, 498 

Magma bismuthi, 57 

magnesiae, 75 
Magnesia, 76 
as sedative antacid, 153 
calcined, 76 
light, 76 
milk of, 75 

for gastric irritation, 153 
Magnesii carbonas, 76 
oxidum, 76 
sulphas, 76 
Magnesium carbonate, 76 
citrate, solution of, 91 
oxide, 76 

as antacid, 153 
as laxative, 163 
sulphate, 76 

as saline purgative, 169, 170 
Malaria, Bass detoxication treatment 

in, 365 
Malarial fever, pernicious, 362 
quinine in, 367 
prophylaxis in, 366 
quinine in, 362, 363 
specific treatment of, 362 
Plasmodia in blood, Mayne and 
Carter treatment of, 365 
Male, gonorrhea in, prevention, 530 

syphilis in, prevention, 531 
Male-fern, 54 

for tape-worms, 175, 176 
Malt sugar, Borcherdt's, 616 
Maltose, 594 
Mammary glands, 485 

cancer of, relation of ovaries and 

corpus luteum to, 475 
description, 485 
extract, administration of, 488 
as oxytocic, 197 
in menorrhagia of menopause, 

488 
in menstruation, 197 
in profuse menstruation, 488 
function, 485 
massage of, 678 



INDEX 



Mammary glands, relation of, to female 
pelvic organs, 486 
to menstruation and corpus 
luteum function, 475 
uses, 488 

vitamines selected by, 584 
Mandrake, 86 

Manganese dioxide, precipitated, 76 
as emmenagogue, 196 
poisoning, 731 
Mangani dioxidum praecipitatum, 76 
Marrow, bone, 511 
Mask, gauze, for inhalations, 516 
Mass, blue, 71 

Vallet's, 69, 394 
Massa ferri carbonatis, 69, 394 

hydrargyri, 71, 339 
Massae, definition, 24 
Massage, 133, 673 
after fractures, 678 
contraindications, 679 
general, effects of, 676 
length of time for, 674 
time for, 675 
indications for, 677 
lubricant for, 674 
of breast, 678 
of face, 678 
of scalp, 679 
prostatic, 678 
uterine, 678 
Masses, definition, 24 
Matzoon, 589 
May apple, 86 

as laxative, 163 
Mayne and Carter treatment for 

malarial plasmodia in blood, 365 
Mead's dextri-maltose, 616 
Meals, frequency of, 607 
Measures and weights in prescription 

writing, 26 
Meat extracts, 511 

1 pound, calories in, 591 
Medical ethics, principles of, of 
American Medical Association, 
819-831 
laws and departments of health, 815 
Medicated inhalations, 514 
Medication, hypodermatic, 533 

post-operative, 302 
Medicinal springs, 652 

diseases benefited by, 709 
Medicine case, pocket, 810 
Mella, definition, 24 
Meninges, inflammation of, convul- 
sions due to, 768, 770! 
Meningitis, cerebrospinal, ^ 573. See 
also Cerebrospinal meningitis. 
meningococcic, antitoxic treatment 

of > 57o ... . . 

Meningococcic meningitis, antitoxic 

treatment of, 570 



Menopause, 481 

artificial, ovarian extract in, 483 
hemorrhage of, thyroid extract for, 

439 
mammary glands after, 486 
menorrhagia of, mammary gland 

extract in, 488 
thyroid preparation for, 436 
Menorrhagia, digitalis in, 225 

of menopause, mammary gland 

extract in, 488 
pituitary extracts in, 455 
Menstrual life, castration during, 

effects of, 481 
Menstruation, 480 

and corpus luteum function, relation 

of mammary gland to, 475 
delayed, corpus luteum in, 475, 476, 

.477. 
digitalis in, 225 
drugs used to increase, 107 
emmenagogues for, 196 
ergot in, 197 

mammary gland extract in, 197 
profuse, mammary gland extract in, 
486 
roentgen ray in, 651 
relation of corpus luteum to, 473 
Mental disturbances, relation to en- 
docrine glands, 403 
Mentality, relation to endocrine secre- 
tions, 402 
Menthol, 77 
Mercurial ointment, 339 

diluted, 339 
Mercuric chloride, 71, 340 
poisoning, 761 
symptoms, 762 
treatment, 762 
iodide, 339 
red, 72, 339 
yellow, 71, 339 
oxide, red, 72 

yellow, 72 
oxycyanide as antiseptic, 117 
salicylate, 72 
Mercurophen as antiseptic, 117 
Mercurous chloride, 71, 339 
chrome-, 220, 340 
iodide, 339 
red, 72,339 
yellow, 71, 339 
Mercury, 71 

administration, 339 

ammonia ted, 72 

as specific, 339 

bichloride of, 71 

in syphilis, 345 

intramuscular injections of, 350 

iodide of, red, 72, 339 

yellow, 71, 339 
poisoning, 731 



862 



INDEX 



Mercury, systemic action of, 341 
Metabolism, arsenic in, 382 
to stimulate, 388 
calcium, in pregnancy, 354, 356 
drugs to modify, 109, 382 

to stimulate, 388 
iodine to stimulate, 389 
iron to stimulate, 394 
Metals, astringent, 142 
Meter, 28 

Methyl alcohol, 238 
poisoning, 764 
symptoms, 765 
treatment, 765 
salicylate, 77, 376 
in rheumatism, 377 
Methylene blue, 77 

as urinary antiseptic, 194 
Methylis salicylas, 77, 376 
Methylthioninae chloridum, 77 
Methylthionine chloride, 77 

as urinary antiseptic, 194 
Metrorrhagia, pituitary extracts in, 

455 

roentgen ray in, 651 
Microorganisms, drugs used to destroy, 

105, no 
Mil, 28 
Milk, boiled, 587 

butter-, 589 

certified, 588 

cow's, content of, 587 

fat content of, 589 

fermented, 589 

forms of serving, 588 

mother's, content of, 587 

of bismuth, 57 

of magnesia, 75 

for gastric irritation, 153 

of sulphur, 97 

pasteurization of, 588 

1 pint, calories in, 591 

skimmed, 589 

sterilization of, 588 

sugar, 594 

in intestinal putrefaction, 175 

vitamines in, 585 
Mineral oil, 84 

as laxative, 163 

springs, 706 
Missed cases in contagious disease, in 
Mistura cretae, 65, 353 

glycyrrhizae composita, 52, 70 
Misturas, definition, 24 
Mitral regurgitation, digitalis in, 221 

stenosis, digitalis in, 222 
Mixture, A B C, 87 

A. C. E., 316 

brown, 52, 70 

chalk, 65, 353 

definition, 24 
Moist heat applications, 668, 669 



Molded silver nitrate, as escharotic, 

139 
Monkshood, 49, 212 
Monosaccharids, 593 
Monsel's solution, 395 
Moro skin test for tuberculosis, 563 
Morphina, 78 
Morphinae hydrochloridum, 78, 260 

sulphas, 78, 260 
Morphine and atropine for postoper- 
ative vomiting, 299 
habit, 716 

atropine as antidote in, 718, 721 
symptoms from withdrawal of 

drug, 719 
treatment, 719 
hydrochloride, 78 
official preparations, 260 
poisoning, epinephrine solutions in, 

470 
sulphate, 78 
Mortality in Graves' disease, 429 
Mosquito bites, 780 

infected, in spread of contagious 
diseases, 112 
Mother's milk, content of, 587 
Mothers, nursing, drugs for, 43 
Mouth, care of, in fever, 330 

focal infections of, danger of, 617 
wash, formula, 620 
Mucilages, definition, 24 
Mucilagines, definition, 24 
Mucilago acaciae, 46 
Mucous membranes, action of alcohol 
on, 239 
drugs used for action on, 106, 140 
of genito urinary system, drugs 

used to stimulate, 107, 195 
of respiratory tract, secretions of, 
drugs used to 
decrease, 108 
to increase, 108 
secretion of, drugs used to 
decrease, 205 
to increase, 201 
Mud baths, 672 
Muriatic acid, diluted, 47 
Murphy drip method of injecting 

saline solution, 543 
Muscarine poisoning, 768 
Muscles, action of digitalis on, 224 
excitation, galvanism in, 641 
extracts from crushed tissues, 

absorption of, shock from, 512 
stimulant, atropine as, 252, 254 
weakened and paralyzed, sinusoidal 
current for, 646 
Mustard as counterirritant, 134 
as emetic, 156 
gas poisoning, 748 
plaster, 134 
Myocarditis, chronic, digitalis in, 223 



INDEX 



863 



Mystery in prescription writing, 

eliminate, 25 
Myxedema, 430 

thyroid preparation for, 437 

Naphthol, 56 

as anthelmintic, 178 
Narcotic effect of alcohol, 713 

law, Harrison, 815 
Nasal douching, 519 
for ozena, 519 
improper, danger from, 519 
solutions for, 520 
spraying, 517 
Nascent ammonium chloride as expec- 
torant, 202 
Nasopharynx, cleansing of, 520 
National Formulary, 21 
Nauheim baths, 672 
Nausea and vomiting, morphine in, 
269 
of pregnancy, corpus luteum in, 478 
Necator americanus, 175 
Neisserian disease, vaccination in, 563 
Neoarsphenamine as specific in syphilis, 
348 
Kolmer and Yagle's conclusions con- 
cerning, 349 
Nephritis, anasarca of, pilocarpine in, 
185 
syphilitic treatment in, 347 
Nerve, phrenic, galvanism to stim- 
ulate, 642 
Nerves, painful, counterirritant for, 

137 
Nervous system affected by lead 
poisoning, 735 
central, drugs used for action on, 

247 
galvanism for, 642 
Neuralgia, atropine in, 252 
intercostal, counterirritant appli- 
cation in, 137 
peripheral, gelsemium in, 259 
trigeminal, alcohol injections in, 242 
Neurasthenia, 691 
climate for, 705 

with low type of circulation, supra- 
renal extract in, 471 
Neuritis, climate for, 705 

morphine in, 268 
Neuro-circulatory asthenia of enlisted 
men, suprarenal gland extracts in, 
466 
New and Nonofficial Remedies, 21 
Nicotine poisoning, acute, 727 
Nightshade, deadly, 55 
Nitrate of potassium, 88 
of silver as escharotic, 139 
for canker sores in mouth, 523 
Nitric acid, 48 

as escharotic, 138 



Nitrite of amyl, 244 
of sodium, 94, 245 
poisoning, treatment, 246 
Nitrites, action, 245 
as vasodilators, 244 
in angina pectoris, 246 
in asthma, 246 
in epilepsy, 241 
over-action, 246 
uses, 246 
Nitrogen monoxide, action, 313 
administration, 313 
as anesthetic, 313 
contraindications, 314 
toxic action, 314 
uses, 314 
Nitrogenous foods, 579 
Nitroglycerin, 244 

as specific in hemorrhage, 369 
in asthma, 247, 470 

acute, 207 
in dysmenorrhea, 247 
in hemorrhage, 225 
in high blood-pressure, 247 
fever, 243, 247 
Nitrous oxide as anesthetic, 313 

oxide-oxygen as anesthetic, 314 
Nocturnal enuresis, thyroid prepara- 
tion for, 436 
Nose and throat, care of, before 

administration of anesthetic, 295 
Nostrils, cleansing of, 519 
Nourishment after operation, 300 
Novocaine, 56 

as local anesthetic, 325 
Nuclein, 510 

in acute infections, 510 
Nucleoproteins, 579 
Nurse for rest cure patients, 694 
Nurse's duties in disinfection of 

contagious disease cases, 112 
Nursing mothers, drugs for, 43 
Nutrient enemata, 605 
indications for, 607 
preparation of bowels for, 605 
solutions for, 605, 606 
Nutritional disturbances, bone marrow 
extracts in, 511 
effect, galvanism for, 642 
Nuts, 591 

1 pound, calories in, 592 
Nux vomica, 78 

administration, 228 
tincture of, 78 
as appetizer, 149 

Oath of Hippocrates, 830 

Obesity, diet in, 627 
infantile, thyroid preparation for, 435 
thyroid preparation for, 437 

Obstetrics, post-pituitary extract in, 
455 



S6 4 



INDEX 



Ocean air, 699 

Oertel system of exercise, 689 
Office dispensing, drugs for, 812 
Official antitoxic serums, 564 

drugs and preparations, 21 

preparations, types of, 22 
Ohm, 639 
Oil, benne, 81 

camphorated, 74 

carron, 74, 353 

castor, 80 

as purgative, 167 

cod-liver, 80. See also Cod-liver oil. 

croton, 81 

as irritant purgative, 171, 172 

for enteroclysis, 529 

laxative, 614 

mineral, 84 

as laxative, 163 

of American wormseed, 78. See also 
Oil, wormseed. 

of betul, 77, 376 

of cade, 78 

of cassia, 78 

of chenopodium, 78 
as anthelmintic, 180 

of cinnamon, 78 

of cloves, 78 

of cottonseed, 79 

of eucalyptus, 79 

of flaxseed, 79 

of juniper berries, 79 

of lavender, 79 

of linseed, 79 

of peppermint, 79 

of pine needles, 80 
in bath, 672 

of sandalwood, 81 

to stimulate mucous membranes, 

195 
of santal, 81 

to stimulate mucous membranes, 

195 

of sweet birch, 77, 376 
of tar, rectified, 80 
of turpentine, 81 

rectified, 81 
of wintergreen, 77, 376 
of wormseed, 78 
olive, 80 

petroleum as laxative, 163 
sprays for atomization, 518 
sweet, 80 
teel, 81 
wormseed, as anthelmintic, 180 

for hook-worms, 179 

for round- worms, 178 
Oils, definition, 24 
Ointment, blue, 71, 339 
chrysarobin, 63 
diachylon, 732 
for colds, formula, 518 



Ointment, Kentish's, 75 

mercurial, 71, 339 
diluted, 339 

of ammoniated mercury, 72, 340 

of belladonna, 55 

of boric acid, 47 

of carbolic acid, 84 

of iodine, 74, 390 

of phenol, 84, 120 

of sulphur, 97 

of surgical paraffin and liquid 
petroleum for burns, 756 

of tannic acid, 48, 145 

of yellow oxide of mercury, 72, 
34o 

of zinc oxide, 99 
Ointments, antiseptic, 132 

definition, 25 

prescription writing for, 35 
Old system, Troy, or Apothecaries, in 

prescription writing, 28 
Olea, definition, 24 
Oleata, definition, 24 
Oleates, definition, 24 
Oleoresin of aspidium, 54 
Oleoresina aspidii, 54 

cubebae, 66 
Oleoresinse, definition, 24 
Oleoresins, definition, 24 
Oleum cadinum, 78 

caryophylli, 78 

cassiae, 78 

chenopodii, 78 

eucalypti, 79 

gossypii seminis, 79 

juniperi, 79 

lavandulae, 79 

lini, 79 

menthae piperitae, 79 

morrhuae, 80 

olivae, 80 

picis liquidae rectificatum, 80 

pini pumilionis, 80 

recini, 80 

santali, 81 

sesami, 81 

terebinthinae, 81 
rectificatum, 81 

theobromatis, 81 

tiglii, 81 
Olive oil, 80 

fat content of, 597 
Onions as carminative, 158 
Operating room, anesthetist's table 
in, 302 
care of patient in, 296 

table, death on, causes, 286 
Operation, carbon dioxide inhalations 
after, 304 

care of patient after, 298 

preparation of patient for, 294 

purging before, 160 



INDEX 



8C 5 



Operation, removal of infected teeth 

and tonsils before, 287, 294 
Ophthalmia neonatorum, nitrate of 

silver for, 147 
Ophthalmology, beta-eucaine hydro- 
chloride in, 324 
holocaine hydrochloride in, 324 
Opii pulvis, 82, 260 
Opium, 82 
action, 262 
on heart, 262 
on spinal cord, 263 
administration, 260 
after hemoptysis, 269 
and ipecac, powder of, 74, 82 
as anesthetic, 260 
coma from, diagnosis, 265 
deodoratum, 82, 260 
deodorized, 82 
extract of, 82 

powdered, 82 
for pain, 267, 268, 269, 270 
granulated, 82 
granulatum, 82, 260 
in angina pectoris, 268 
in cerebrospinal meningitis, 269 
in colic, 268 
in diarrhea, 269 
in incurable cancer, 269 
in nausea and vomiting, 269 
in pulmonary tuberculosis, 269 
in sciatica, 268 
in uremic neuralgias, 269 
official preparations, 260 
over-action, 264 
poisoning, chronic, 267 

epinephrine solutions in, 470 
treatment, 265 
powdered, 82 
tincture of, 82 
camphorated, 82 
deodorized, 82 
to cause sleep, 269 
toxic action, 265 
uses, 267 
Oranges, 1 pound, calories in, 591 
Organotherapy, 399 
Orphol, 57, 155 
Osteomalacia, 354 

due to disturbances of endocrine 

glands, 482 
treatment, 482 
Osteopathy, 680 
Otitis media, 797 
Ouabain, crystallized, 226 
Oudin current, 646 

Ovarian disturbances, parotid gland, 
extracts in, 509 
extract, administration, 484 
in artificial menopause, 483 
in slowly developing girls, 483 
in total hysterectomy, 483 
55 



Ovarian disturbances, residue, 484 
Ovaries, 478 

and corpus luteum, relation of, to 
mammary cancer, 475 

function, 478 

uses, 483 

tf-ray treatment of, in osteomalacia, 
483 
Overweight, 39 

with amenorrhea, 

corpus luteum in, 476 
Oxgall, 68^ 

as laxative, 162 

powdered extract of, 68 
Oxide of iron, saccharated, 396 

of lead, 732 

of mercury, red, 72 
yellow, 72 

of zinc, 99 
Oxygen inhalations, 315, 513 
Oxytocics, 108, 196 
Oxyuris vermicularis, 175 
Ozena, inhalation formula for, 515 

nasal douching for, 519 

Packs, 662 

cold, method, 670 
Pain, acute, drugs used to stop, 108 

benzyl benzoate to quiet, 261, 262 

drugs used to stop, 259 

effects of, on suprarenal activity, 463 

hysterical, faradism for, 645 

opium for, 267, 268, 269, 270 

pelvic in menstrual disturbance, 
corpus luteum in, 476 
Painful joints and nerves, counter- 
irritant for, 137 
Painless labor, 319 
Paints, poisoning from, 737 
Pancreas, 504 

carbohydrate tolerance of, test for, 
506 

function, 504 

relation of, to diabetes, 504 
to glycosuria, 504 
Pancreatic juice, 504 
Pancreatin, 82 
Pancreatinum, 82 
Paquelin cautery for counterirritation, 

136 
Paraffin treatment of burns, 755 
Paraform, 83, 116 
Paraformaldehyde, 83, 116 
Paraformaldehydum, 8$, 116 
Paraldehyde, 83 

action, 279 

as hypnotic, 279 

description, 279 

habit, 280 

over-action, 280 

poisoning, treatment, 280 

toxic action, 280 



866 



INDEX 



Paraldeyhyde, uses, 280 
Paraldehydum, 83 

Paralysis agitans, scopolamine in, 250 
infantile, treatment, 574 
strychnine in, 230 
Paralytic stage of ether, 311 
Parasites, intestinal, 175 

drugs used to remove, 107 
skin, drugs used to destroy, 105 
Parasiticides, 105, 125 
Parasulphondichloraminobenzoic acid 

as antiseptic, 118 
Parathyroid glands, 440 

control of calcium metabolism by, 

441 
extirpation, symptoms, 440 
extracts in muscle irritability, 445 

uses of, 445 
functions, 441, 442 
tissue, transplantation of, 441 
Parathyroidectomy, symptoms caused 

by, calcium in, 441 
Paratoluenesulphodichloramide, as 

antiseptic, 118 
Paratyphoid fever, prevention of, 559 

vaccination in, 559, 560 
Paregoric, 82, 260 
Parotid glands, 508 

extracts in ovarian disturbances, 

5°9 
Parturition, oxytocics in, 197 

Pasteur protective inoculations in 
hydrophobia, 564 

Pasteurization of milk, 588 

Pathologic conditions present, influ- 
ence of, in dosage, 39 

Patient, care of, after operation, 298 
in operating room, 296 
pre-operative care of, 292 
preparation of, for operation, 294 

Peanut butter, 591 

Peanuts, fat content of, 597 

Pecans, fat content of, 597 

Pediculosis, 793 

Pellagra, diet in, 631 

Pelletierinae tannas, 83 

Pelletierine tannate, 83 

for tape-worms, 175, 177 

Pelvic pain in menstrual disturbance, 
corpus luteum in, 476 

Peppermint, oil of, 79 
spirit of, 80 
water, 80 

for administering drugs in pre- 
scriptions, 32 

Pepsin, 83 

as digestant, 151 

Pepsinum, 83 

Perineum, ice to, 670 

Peripheral nerve irritation, atropin 
to inhibit, 252 
neuralgias, gelsemium in, 259 



Peristalsis, drugs used to increase, 106 

intestinal, ergot to promote, 234 
Pernicious malarial fever, 362 
quinine in, 367 
vomiting of pregnancy, nutrient 
enema for, 605 
Peroxide of hydrogen in sterilization, 
122 
solution of, 75 
as antiseptic, 119 
Perspiration, drugs used to decrease, 
107, 186 
to increase, 107, 183 
excessive, 796 
profuse, treatment, 187 
Pertussis. See Whooping-cough. 
Peruvian bark, red, 63, 357 

yellow, 63, 357 
Petrissage, 675, 676 
Petrolatum, 84 
album, 84 
liquidum, 84 
Petroleum jelly, 84 
white, 84 
liquid, 84 

for burns, 756 
oil as laxative, 163 
Pharmacal incompatibility, 36 
Pharmacopoeia, United States, 21, 22 
Phenacetin, 46, 336 
Phenazone, 52, 337 
Phenobarbital, 283 
Phenobarbital-sodium, 283 
Phenol, 84, 119 
action of, 120 
glycerite, 84 
in sterilization, 119 
liquef actum, 84, 119, 122 
ointment of, 84 
poisoning, treatment, 121 
solutions as antiseptics, 118 
toxic action of, 120 
uses, 122 
Phenolphthalein, 84 

as laxative, 165 
Phenolphthaleinum, 84 
Phenyl salicylate, 85, 381 
in acute diarrhea, 382 
in intestinal putrefaction, 173 
in typhoid fever, 382 
Phenylcinchoninic acid, 48 

to increase uric acid excretion, 
39S 
Phenylethylbarbituric acid, 283 
Phenylis salicylate, 85 
Phosgene gas poisoning, 749 
Phosphate of soda, 94 
effervescent, 94 
exsiccated, 94 
Phosphatids, 597 
Phospholipins, 597, 598 
Phosphoric acid, diluted, 48 



INDEX 



867 



Phosphorus, pills of, 738 
poisoning, 738 

acute, treatment, 739 
chronic, 740 
toxic action, 739 
Physical exercise, 680. See also Exer- 
cises. 
Physician in charge of sanatorium for 
rest cure, 694 
young, ethical suggestions to, 831 
practical advice to, 800 
Physiology, abnormal, influence of, 

in dosage, 39 
Physostigminae salicylas, 85, 256 
Physostigmine, 85 

salicylate, 85 
Picric acid, 99 

as emollient, 130 
Pigmentation in Addison's disease, 

464 
Pill, Blaud's, 394 
blue, 71 
compound cathartic, 71 

as irritant purgative, 172 
rhubarb, 50, 91, 164 
definition, 24 

of aloes, prescription for, 51 
of asafetida, 54 
of ferrous carbonate, 394 
of phosphorus, 738 
official compounded, prescription for, 

.33 

with several ingredients, prescription 
for, 34 
Pilocarpine hydrochloridum, 85 

as diaphoretic, 184 
Pilocarpine, 85, 184 

action of, 184, 185 

administration, 184 

hydrochloride, 85 
as diaphoretic, 184 

poisoning, treatment, 185 

toxic action, 185 

uses, 185 
Pilocarpus, 85, 184 

action, 184 

administration, 184 

as diaphoretic, 184 

fluidextract of, 85 

over-action, 185 

poisoning, treatment, 185 

toxic action, 185 

uses, 185 
Pilulae aloes, 50 

asafcetidae, 54 

definition, 24 

ferri carbonatis, 394 

phosphori, 738 

rhei composite, 50, 91, 164 
Pine needle bath, 672 

needles, oil of, 80 
in bath, 672 



Pineal gland, 500 
description, 500 
extract in defective development 

of children, 503 
function, 501 
inhibition of sexual, development 

by, 501, 503 
insufficiency of, increased sexual 
development from, 501, 503 
Pinkroot, 95 

as anthelmintic, 178 
Pin- worms, 175 

anthelmintics for, 178 
treatment, 178 
Pituitary gland, 445 
description, 445 
desiccated, 73 

extracts, action on circulation, 211 
administration, 457 
after abdominal operations, 455 
as oxytocic, 197 
for increasing peristalsis, 158 
from anterior lobe, in dystrophy 
adioposogenitalis, 454 
in infantilism, 452 
in rickets, 457 
from posterior lobe in cardiac 
failure and shock with 
low blood-pressure, 455 
in diabetes insipidus, 448, 
456 299 

in obstetrics, 455 
injection of, after opera- 
tion, in Addison's disease, 469 
in bladder paralysis after lapa- 
rotomy, 456 
in menorrhagia, 455 
in metrorrhagia, 455 
uses, 454 

whole gland, in epilepsy, 456 
in pituitary headache, 454 
in vasomotor disturbances, 

456 
function, 446 
hypersecretion of, 450 
hyposecretion of, 452 

typical evidences of, 453 
posterior lobe and sugar metab- 
olism, 447 
extracts, uses of, 447 
headache, whole gland extract in 

454 
Placenta, 485 
Placental extracts, 485 
Plaster, adhesive, 732 

diachylon, 732 

definition, 23 

lead, 732 

of belladonna, 55 

of cantharides for blistering, 135 

rosin, 732 

spice, 134 



868 



INDEX 



Plumbi acetas, 85, 732 

oxidum, 732 
Plumbism, 733 
Pneumonia, digitalis in, 224 

treatment of, 568 
Pocket inhaling tubes, 518 

medicine case, 810 
Podophylli, resin of, 86 
Podophyllum, 86 
as laxative, 163 
Poison tablet of corrosive mercuric 
chloride, 71 
sublimate, 340 
Poisoning, acetanilid, treatment, 335 
aconite, treatment, 212 
alcohol, 711 

treatment, 241 
arsenic, 731 

acute, treatment, 386 
chronic, 387 
treatment, 388 
atropine, treatment, 252 
barbital, treatment, 283 
bromide, treatment, 274 
by canned goods, 766 
caffeine, 216 
carbon monoxide, 745 

treatment, 747 
chloral, 277 

chronic, 277, 278 
treatment, 277 
chlorine, 748 

chloroform, treatment, 308 
cocaine hydrochloride, treatment, 

323 
colchicum seed, treatment, 374 
corrosive sublimate, 761 
symptoms, 762 
treatment, 762 
digitalis, treatment, 220 
drug, 42 

acute, aims of treatment, 758 
treatment, 757 

antidote for, atropin as, 256 

chronic, 43, 711 
ergot, 233 

treatment, 233 
formaldehyde, treatment of, 115 
from dye-stuffs, 740 
from paints, 737 
from war gas, 748 
gelsemium, treatment, 259 
heroin, 718 
hydrofluoric acid, 731 
illuminating gas, 745 

treatment, 747 
industrial, 731 
iodine, chronic, 392 
treatment, 392 
ipecac, treatment, 204 
ivy, 781 
lead, 732 



Poisoning, lead, acute, treatment of, 
733 
chronic, 733 
symptoms, 734 
treatment, 736 
nervous system in, 735 
manganese, 731 
mercuric chloride, 761 
symptoms, 762 
treatment, 762 
mercury, 731 
methyl alcohol, 764 
symptoms, 765 
treatment, 765 
morphine, 716 
muscarine, 768 
mustard gas, 748 
nicotine, acute, 727 
nitrite, treatment, 246 
opium, chronic, 267 

treatment, 265 
paraldehyde, treatment, 280 
phenol, treatment, 121 
phosgene gas, 749 
phosphorus, 738 

acute, treatment, 739 
chronic, 740 
pilocarpine, treatment, 185 
prevention of, by thyroid gland, 

408 
primrose, 782 
protein, 551, 553 

relation of endocrine glands to, 

552 
to desensitize a patient to, 553 
treatment, 554 
ptomaine, 618 
quinine, treatment, 362 
salicylic acid, treatment, 379 
silver nitrate, 147 

acute, treatment, 147 
solanine, 593, 630 
strophanthus, treatment, 227 
strychnine, bromides in, 275 

treatment, 229 
sulphonal, treatment, 282 
toadstool, 768 
tobacco, acute, 727 

chronic, 727 
trinitrotoluene, 741 
trional, treatment, 282 
uranium, 731 
wood alcohol, 764 
symptoms, 765 
treatment, 765 
Poliomyelitis, anterior, treatment, 547 
Pomegranate, 70 

fluidextract of, 70 
Port, alcohol content of, 596 
Post-operative medication, 302 
treatment of bowels, 300 
vomiting, care of, 299 



INDEX 



869 



Post-pituitary extract injection after 

operation, 299 
Potash, caustic, 88 

as escharotic, 139 
Potassii bitartras, 86 
bromidum, 86 
chloras, 87 
citras, 87 

effervescens, 87 
et sodii tartras, 88 
iodidum, 88, 390 
hydroxidum, 88 
nitras, 88 
permanganas, 89 
Potassium and sodium tartrate, 88 
as saline purgative, 170 
bitartrate, 86 
bromide, 86 

action, 272 

as hypnotic, 272 

description, 272 

over-action, 273 

toxic action, 274 

uses, 274 
chlorate, 87 

solution as gargle, 522 
citrate, 87 

effervescent, 87 

for acidity of urine, 190 

to render urine alkaline, 191 
hydroxide, 88 

as escharotic, 139 
iodide, 88, 390 

administration, 390 
mercuric iodide, as antiseptic, 117 
nitrate, 88 
permanganate, 89 
Potatoes, 59 

1 pound, calories in, 591 
Poultry, 1 pound, calories in, 591 
Powder, compound effervescing, 49 

licorice, 162 

rhubarb, 165 
definition, 24 
Dover's, 74, 82, 203, 260 
dusting, 126 

effervescing, compound, 88 
Gregory's, 91, 165 
in prescription writing, 34 
jalap, compound, 74 
licorice, compound, 70, 93 
of ipecac and opium, 74, 82, 203, 260 
of rhubarb, compound, 91 
seidlitz, 49, 88 
Powdered extract of opium, 82 

of oxgall, 68 
ipecac root, 74 
opium, 82 
Practical advice to young physicians, 

800 
Practitioner, young, ethical sugges- 
tions to, 831 



Precipitate, red, 72 

white, 72 
Precipitated calcium carbonate, 58 
chalk, 58, 353 
manganese dioxide, 76 

as emmenagogue, 196 
sulphur, 97 
zinc carbonate, 99 
Pregnancy, calcium in last months of, 
444 
metabolism in, 354, 356 
corpus luteum of, 474 

relation of, to vomiting of preg- 
nancy, 474, 477 
diet in, 623 

in Graves' disease, 417 
nausea of, corpus luteum in, 478 
syphilis in, 346 
thyroid in, 407 

vomiting of, nutrient enema for, 605 
thyroid extract in, 43 7 
Pre-operative care of patient, 292 
Preparations and drugs, official, 21 
official, types of, 22 
that are specific, 109, S3^> 
Prepared chalk, 65, 353 
Prescription, art of writing, 17 
evolution of, 32 

for more than one ingredient, S3 
for official compounded pill, S3 
for pill with several ingredients, 34 
writing, 29 

abbreviations for, 32 

aim of, 31 

apothecaries system in, 28 

art of, 17 

capsules in, 34 

conditions modifying action of a 

drug, 40 
copy retained, 31 
cumulative effects of drugs in, 42 
decimal system in, 26, 27 
disguising disagreeable drugs in, 32 
do and dont's of, 37 
dosage in, 37 
drop dosage, 35 
eliminate mystery in, 25 
English in, 25 

incompatibility of drugs in, $6 
individualized for particular 

patient, 30 
Latin in, 25 
ointments in, 35 
old system in, 28 
powders in, 34 
rectal suppository in, 35 
simple, 25, 31 
table of equivalents for, 29 
of liquids for, 28 
of solids for, 28 
Troy system in, 28 
weights and measures in, 26 



870 



INDEX 



Prevention of venereal diseases, 343 

infection, 530 
Primrose poisoning, 782 
Principles of therapeutics, 17 
Procaine, 56 

as local anesthetic, 325 
Proganol, 148 
Progressive circulatory insufficiency, 

reason for, 208 
Prohibition law, 815 
Prosecretin, 506 
Prostate gland, 492 
description, 492 
Prostration, heat, 773 
Protan as astringent, 145 
Protargol, 148 
Protective and curative serums, 564 

vaccines, 557 
Protein, 578 

daily requirement of, 578 
digestion, 580 

approximate time for, 580 
foods, amount required, 578 
idiosyncrasy, cutaneous test for, 554 
intoxication, value of fever in 

fighting, 326 
poisoning, 551, 553 

relation of endocrine glands to, 

to desensitize a patient to, 553 
treatment, 554 
sources of, 580 
Protoiodide of mercury, 71 
Prunus virginiana, 89 
Pruritus, 777 

acute, treatment, 778 
treatment, 778 
vulvae, 779 
Psoriasis, 789 
Psychic condition, recognition of, 

before operation, 287 
Ptomaine poisoning, 618 
Puberty, thyroid preparation for, 435 
Puerperal eclampsia, thyroid extract 
in, 437 
veratrum viride in, 214 
Pulmonary tuberculosis, morphin in, 

269 
Pulveres, definition, 24 
Pulvis effervescens compositus, 88 
as saline purgative, 169 
glycyrrhizae compositus, 70, 92 
ipecacuanhas et opii, 74, 82, 203, 260 
jalapas compositus, 74 

as irritant purgative, 172 
Puncture headache, 571 

lumbar, 569. See also Lumbar 
puncture. 
Pupils, contraction of, eserine for, 255 
dilatation of, atropine for, 255 
gelsemine in, 259 
homatropine for, 255, 256 



Purgatives, 107, 166 
definition, 158 
irritant, 107, 171 
definition, 158 
saline, 107, 168 

administration, 170 
definition, 158 
indications for, 170 
Purging before operations, 160 
Purified antidiphtheric serum, 564 
antitetanic serum, 565 
talc, 97 
Purin, 586 
bases, 586 
bodies, 586 
Purin-free diet, 586 
Pus, heat application in presence of, 
668 
removal of, by aspiration, 536 
Putrefaction, intestinal, chronic 
poisoning from, 618 
drugs used to diminish, 107, 173 
products, 581 
Putrefactive bacteria in intestines, 
616 

treatment for, 618 
Pyorrhea, treatment of, before major 

operation, 294 
Pyrogallic acid, 89 
Pyrogallol, 89 

Quartz lamp for heliotherapy, 637 

Quassia, 89 

Quebracho, 54 

Quevenne's iron, 69 

Quicklime, 60 

Quicksilver, 71, 339 

Quinina, 90 

Quininas bisulphas, 90, 357 

dihydrochloridum, 90, 357 

et ureae hydrochloridum, 90, 357 

hydrobromidum, 90, 358 

hydrochloridum, 90, 358 

sulphas, 90, 358 
Quinine, 90 

action, 359 

administration, 357 

and urea hydrochloride, 90, 357 
injection to destroy tissue, 368 

as appetizer, 149 

as tonic, 368 

bisulphate, 357 

dihydro chloride, 90, 357 

hydrobromide, 90, 358 

hydrochloride, 90, 358 

in malarial fever, 362, 363 

over-action, 361 

poisoning, treatment, 362 

sulphate, 90, 358 
as oxytocic, 197 
in parturition, 197 

toxic action, 362 



INDEX 



871 



Rabies, prevention of, 564 
Radio-active substances, 652 
Radiotherapy, 650 

necessity for protection in, 650 
Radium, 654 

in cancer of cervix, 655 
in cataract, 656 
in epithelioma, 656 
treatment of thyroid, 428 

of uterus, symptoms following, 
656 
value of, in treatment of malignant 

growths, 654 
water, dosage, 653 
Rapidity of absorption of drugs, 44 
Reaction, anaphylactic, prevention of, 

552 
Rectal anesthesia, 287, 290, 291 
contraindications for, 292 
indications for, 292 
feeding, 605. See also Enema. 
suppository in prescription writing, 

35 
Rectified oil of tar, 80 
of turpentine, 81 
Red cinchona, 357 

iodide of mercury, 72, 339 

description, 339 
mercuric iodide, 72 

oxide, 72 
Peruvian bark, 63, 357 
precipitate, 72, 340 
Reduced iron, 69, 395 
Regurgitation, mitral, digitalis in, 221 
Relation of skin to systemic condition, 

776 
Renal and hepatic colic, chloroform in, 
307 
colic, morphine in, 268 
Reportable diseases, 817 
Resin of podophylli, 86 
Resina podophylli, 86 
Resinas, definition, 24 
Resins, definition, 24 
Resorcin, 90 
Resorcinol, 90 

Respiration, artificial, in opium poison- 
ing, 266 
Schafer method, 752 
Sylvester method, 752 
disturbance of regularity of, in 
chloroform anesthesia, 306, 308 
Respiratory center, atropine to stimu- 
late, 252, 254 
conditions, before administration of 

anesthetic, 293 
failure in ether anesthesia, treat- 
ment, 312 
tract, drugs used for action on, 108, 
198 
Rest cure, 690 

care of constipation in, 696 



Rest cure, for mental derangement, 698 
forced feeding in, 694 
in hysteria, 698 
modified, 695 
nurse in, 694 
object of, 693 
physician in, 694 
production of sleep in, 696 

importance of, in serious illness, 693 
Rheum, 90 

Rheumatism, acute, sodium salicylate 
in, 379 

definition, 375 

salicylic acid in, 375 
Rhubarb, 90 

as laxative, 164 

compound powder of, 91 

extract of, 90 

fluidextract of, 90 

pill, compound, 50, 91, 164 

powder, compound, 165 

syrup of, aromatic, 91 

tincture of, aromatic, 91 
Rice, 1 pound, calories in, 591 

value of, 592 
Rickets, 356 

anterior pituitary extract in, 457 

cod-liver oil in, 583 

diet in, 630 

thymus gland extracts in, 500 
Riding, bicycle, as exercise, 685 

horseback, as exercise, 686 
Ringworm, 790 

solutions of formaldehyde for, 116 
Rochelle salt, 88 

as saline purgative, 170 
Roentgen-ray, 649 

for dangerously enlarged thymus 
gland, 499 _ 

for metrorrhagia, 651 

for ovaries in osteomalacia, 483 

for thyroid in Graves' disease, 427 

for uterine fibroids, 651 
Room, disinfection of, 114 
Rosin plaster, 732 
Round-worms, 175, 177 

anthelmintics for, 177 

santonin formula for, 91 

treatment, 177 
Rowing as exercise, 686 
Rubbing with alcohol, 667 
Rum, alcohol content of, 596 
Running as exercise, 685 
Russian baths, 661 
Rye, ergot of, 68 

Saccharated ferrous carbonate, 68, 

394 
oxide of iron, 396 
Saccharin, 56, 595 
Saccharose, 594 
Salicylate of soda, 94 



872 



INDEX 



Salicylic acid, 48, 376 
action, 377 ^ 
administration, 376 
as escharotic, 139 
contraindications for, 381 
for warts and callous skin, 377 
in rheumatism, 375 
over-action, 379 
poisoning, treatment, 379 
toxic action, 379 
uses, 379 
Salicylism, 378, 379 
Saline purgatives, 107, 168 
administration, 170 
definition, 158 
indications for, 170 
solution, enema of, after operation, 
298' 
injections into subcutaneous cellu- 
lar tissue, 542 
intravenous, 540 
indications for, 541 
method, 540 
solutions for, 540 
Murphy drip method of injecting, 

543 
Salivary glands. See Parotid glands. 
Salol, 85, 381 

in intestinal putrefaction, 173 
Salt deposits, distilled water to 
prevent, 707 

epsom, 76 

Glauber's, 95 

Rochelle, 88 

sea, in bath, 671 
Salt-free diet, 622 
Saltpeter, 88 
Salts, 599 

bile, 508 

calcium, 599 
Salvarsan as specific, in syphilis, 347 

in syphilis, 345 
Sandalwood, oil of, 81 

to stimulate mucous membranes, 

195 

Santal, oil of, 81 

to stimulate mucous membranes, 

195 
Santonin, 91 

for round-worms, 177, 178 
Santoninum, 91 
Sapo mollis, 92 

Sauterne, alcohol content of, 596 
Scabies, 791 
Scalp, massage of, 679 
Scarlet red, 132 
Schafer method of artificial respiration, 

752 
Schick test in susceptibility to 

diphtheria, 566 
Schott system of exercise, 689 
Sciatic pain, morphine in, 268 



Scilla, 92 

Sclerosis, iodine in, 393 

Scoparius as diuretic, 190 

Scopolamine hydrobromidum, 92, 319 

as cerebral stimulant, 249 
Scopolamine, 249 
and morphine as local anesthetic, 

3i9 
as hypnotic, 271 
hydrobromide, 92 
action, 283 
as hypnotic, 283 
description, 283 
over-action, 284 
uses, 284 
in paralysis agitans, 250 
in spinal irritability, 250 
Scotch douche, 673 
Scurvy, antiscorbutic foods for, 584 

diet in, 629 
Sea salt in bath, 671 
Seasickness, 774 

preventive treatment, 775 
Secretin, 506 
Secretions, atropine to dry up, 252, 

253 

of mucous membranes, drugs used 
to decrease, 106, 205 
to increase, 201 
of respiratory tract, drugs used 
to decrease, 108 
to increase, 108 
Seed, colchicum, 64 
Seidlitz powder, 49, 88 

as saline purgative, 169 
Seminal emissions, ice to stop, 670 
Senna, 92 

as laxative, 165 
fluidextract of, 92, 165 
Sensitization, 550, 552 
Septicemia, yeast in, 510 
Serum, 547 

antimeningococcic, 573 
antidiphthericum, 564 
purificatum, 564 
siccum, 564 
antidysenteric, 569 
antipneumococcic, 568 
antitetanicum, 565 
purificatum, 565 
siccum, 565 
antitoxic, official, 564 
arsphenaminized, preparation of, 

348 
as specific in hemorrhage, 369, 

37o 
horse, susceptibility of patient to, 

5 6 5 ... 

in treatment of anterior poliomyelitis, 

574 
of chorea, 574 
protective and curative, 564 



INDEX 



873 



Sexual development, increased rapidity 
of, by insufficiency of pineal 
gland, 501, 503 < 
inhibition of, by pineal gland, 501, 

503 
Sherry, alcohol content of, 596^ 

Shock and cardiac failure with low 
blood-pressure, post-pituitary ex- 
tract in, 455 
camphor in, 257 

epinephrine intraspinally in, 470 
ergot in, 234 

following lumbar puncture, 572 
from absorption of muscle extracts 

from crushed tissues, 512 
suprarenal gland extract in, 465, 466 
Silver foil in surgical dressing, 147 
nitrate, 53 
action, 146 
administration, 146 
as astringent, 146 
as escharotic, 139 
for canker sores in mouth, 523 
poisoning, 147 

acute, treatment, 147 
toxic action, 147 
uses, 147 
preparations, N. N. R., 148 
Simple cerate, 62 

disturbances of surface of body, 

treatment of, 776 
prescription writing, 25 
Sinusoidal current, 645 

for weakened and paralyzed mus- 
cles, 646 
Sitting up after operation, 301 
Sitz bath, hot, 671 
Skimmed milk, 589 
Skin, action of alcohol on, 239 

activity of, drugs used to stimulate, 

107, 183 
arsenic as stimulant to, 389 
as indicator of health of individual, 

776 
drugs used internally for action on, 

106, 107, 125, 183 
dry, thyroid preparation for, 434 
eruptions on, drugs causing, 43 
erythema of, drugs that cause, 776 
in endocrine disturbances, 402 
inflammation of, drugs in, 126 
irritations of, foods causing, 776 
luetin test, in syphilis, 344 
parasites, drugs used to destroy, 105 
relation of, to systemic condition, 776 
test, Moro, for tuberculosis, 563 
Sleep, causes of, 271 

drugs used to cause, 108, 270 
morphin to produce, 269 
production of, in rest cure patients, 

696 
twilight, 319 



Small-pox, prevention of, 557 

vaccination in, 557 
Snakebite, treatment for, 138 
Soap liniment, 75 

soft, 75, 92 
soft, 92 

liniment of, 75, 92 
So-called athletics, 687 
Soda, caustic, 94 

as escharotic, 140 
Sodii arsenilas, 383 
benzoas, 93 
benzosulphinidum, 56 
bicarbonas, 93 
boras, 93 
bromidum, 93 
cacodylas, 93, 383 
citras, 93 
hydroxidum, 94 
iodidum, 94, 390 
nitris, 94 
phosphas, 94 

effervescens, 94 

exsiccatus, 94 
salicylas, 94 
sulphas, 95 
Sodium and potassium tartrate, 88 
arsenilas, 383 
arsphenamine, 348 
benzoate, 93 
bicarbonate, 93 

as digestant, 151 

for gastric acidity, 152 
biphosphate to render urine acid, 192 
borate, 93 
bromide, 93 

action, 272 

as hypnotic, 272 

description, 272 

over-action, 273 

toxic action, 274 

uses, 274 
cacodylate, 93, 383 
chloride, 599 
citrate, 93 

for acidity of urine, 190 

to render urine alkaline, 191 
dimethylarsenate, 383 
glycocholate as laxative, 162 
hydroxide, 94 

as escharotic, 140 
iodide, 94, 390 

administration, 390 
nitrite, 94, 245 
oxymercuryorthonitrophenolate, as 

antiseptic, 117 
paratoluenesulphochloramide, as an- 
tiseptic, 118 
phosphate, 94 

as saline purgative, 170 

effervescent, 94 

exsiccated, 94 



8 74 



INDEX 



Sodium salicylas, 376 

salicylate, 48, 94, 376 

in acute rheumatism, 379 

sulphate, 95 

as saline purgative, 169, 170 

taurocholate, as laxative, 162 
Soft soap, 92 

soap as counterirritant, 133 
soap liniment, 75, 92 
Solanine poisoning, 593, 630 
Solargentum-squibb, 148 
Solids, table of, for prescription writing, 

28 
Soluble ferric phosphate, 395 
Solution, Dakin's as antiseptic, 118 

Donovan's, 53 

for disinfection of excreta, 113 

Fowler's, 54, 382 

Labarraque's, 60 
as antiseptic, 118 

Lugol's, 73 

of calcium hydroxide, 352 

of ferric subsulphate, 395 

of formaldehyde, 75, 115 

of lead subacetate, 86 

of magnesium citrate, 91 

of peroxide of hydrogen, 75 

of potassium arsenite, 382 
administration, 383 

to attract and kill flies, 781 
Sophol, 148 
Spanish flies, 61 
Sparteine sulphas, 95 
Sparteine sulphate, 95 
Spasm, benzyl benzoate to relax, 261, 
262 

drugs used to relax, 206 

of respiratory tract, drugs used to 
relax, 108 
Spasmodic croup, drugs used to relax 

spasm in, 206 
Spasmophilia, due to disturbance of 

parathyroids, 444 
Spasmophilic type of convulsions, 768, 
769 
treatment, 770 
Specific drugs and preparations, 109, 

338 
Specifics, drugs used as, 109, 371 

in hemorrhage, serums as, 369, 370 
Spelter chills, 738 
Spice plaster, 134 
Spices, 612 
Spigelia, 95 

as anthelmintic, 178 

fluidextract of, 95 
Spinal anesthesia, 320 

cord, drugs used to depress, 108, 

257 

to stimulate, 108, 248 

morphine as stimulant to, 263 

fluid, diagnosing condition by, 570 



Spinal irritability, bromides in, 274 
scopolamine in, 250 

puncture, 569. See also Lumbar 
puncture. 
Spirits definition, 24 

of ammonia, aromatic, 51 

of camphor, 61, 256 

of chloroform, 63, 304 

of ether, 50, 309 

of glonoin, 244 

of juniper, 79 
compound, 79 

of nitroglycerin, 244 

of peppermint, 80 

of turpentine, 81 
Spiritus aetheris, 50, 309 

ammoniae aroma ticus, 51 
for flatulence, 152 

camphorae, 61, 256 

chloroformi, 63, 304 

definition, 24 

glycerylis nitratis, 244 

juniperi, 79 
composita, 79 
Spleen, 507 

function, 507 
Splenectomy, indications for, 507 
Sponging, alcohol, 667 

cold, 663, 665 
Sprained ankle, hot foot bath for, 669 
Sprains, alcohol pack for, 241 

massage for, value of, 678 
Spraying, nasal, 517 
Springs. See also Waters. 

alkaline, 709 

arsenic, 709 

carbonated, 708 

cathartic, 708, 709 

classes of, 708 

hot, 708 

iron, 709 

lithium, 709 

medicinal, 652 

classification of, 653 
diseases benefited by, 709 

mineral, 706 
Squill, 92 

as diuretic, 190 

fluidextract of, 92 

tincture of, 92 

vinegar of, 92 
Staphisagria, 95 
Starvation before operation, 295 

treatment in diabetes mellitus, 624 
State department of Health, 818 
Static electricity, 648 
Stature, in endorine disturbances, 402 
Stavesacre, 95 
Stearate of zinc, 99 
Stenosis, aortic, broken compensation 
in, digitalis in, 222 

mitral, digitalis in, 222 



INDEX 



875 



Sterility from x-ray, 651 

thyroid extract in, 409 
Sterilization, 119 

of milk, 588 
Stomach, condition of, modifying ac- 
tion of a drug, 40 

contractions of, faradism to cause, 

645, 
drugs]usedfor local action in, 106, 148 
to relieve irritation in, 153 
Stovaine and alypin as local anesthetic, 

325 
Stramonium, 95 

as cerebral stimulant, 250 
Stroke, heat, 773 
Strophanthin, 96 

action on circulation, 211 
Strophanthinum, 96, 226 
Strophanthus, 96 

action, 226 

administration, 226 

in sudden heart failure, 227 

over-action, 227 

poisoning, treatment, 227 

tincture of, 96 

to strengthen heart, 226 

toxic action, 227 

uses, 227 
Strychninae nitras, 96 

sulphas, 96 
Strychnine, 96 

action, 228 

on circulation, 210 

administration, 228 

in paralysis, 230 

in profuse sweating, 230 

in sudden heart failure, 231 

indications for use of, 229, 231 

nitrate, 96 

over-action, 229 

poisoning, bromides in, 275 
treatment, 229 

sulphate, 96 

to strengthen heart, 229 

toxic action, 229 

uses, 229 
Stupe, turpentine, 135 
Sty, 786 

Styptics, 143, 369 
Stypticin, 65 

Subacetate of lead, solution, 86 
Subcarbonate of bismuth, action of, 154 
administration, 154 
uses, 155 
Subchloride of mercury, 71 
Subcutaneous vaccination, 559 
Subgallate of bismuth, for gastric 

irritation, 155 
Sublimed sulphur, 97 
Subnitrate of bismuth for gastric 

irritation, 153, 155 
Sudden death, 743 



Sugar, 593 
cane, 594 
grape, 594 
metabolism and posterior lobe of 

pituitary gland, 447 
milk, e 594 

in intestinal putrefaction, 175 
of lead, 85, 732 
Sulphate of copper as emetic, 156 
as escharotic, 139 
of sodium, 95 
of sparteine, 95 
of zinc, 100 
as emetic, 156 
Sulphonal, 96 
action, 281 
as hypnotic, 281 
description, 281 
habit, 282 
over-action, 281 
poisoning, treatment, 282 
uses, 282 
Sulphonethylmethane, 96, 281 
Sulphonethylmethanum, 96 
Sulphonmethane, 96, 281 
Sulphonmethanum, 96 
Sulphur as laxative, 165 
baths, 672 
flowers of, 97 
for disinfecting, 114 
fumigation, 114 
lotum, 96, 165 
milk of, 97 
ointment of, 97 
praecipitatum, 97 
precipitated, 97 
sublimatum, 97 
sublimed, 97 
washed, 96 
Sulphurated lime, 59 
Sun bath, dosage, 636 
exposures, 635 
in tuberculosis, 636 
lamp, Alpine, for heliotherapy, 637 
Sunlight, value of, in prevention of 

disease, 637 
Sunstroke, 771 
coma from, 744 
reducing temperature in, 666 
treatment, 772 
Suppositoria, definition^ 24 
Suppositories, definition, 24 
glycerin, 69 

rectal, in prescription writing, 35 
Suprarenal glands, 458 
administration, 471 
description, 458 
desiccated, 97, 471 
effect of infection on, 460, 462, 463 
extract, action on circulation, 211 
in acute diseases with depres- 
sion, 328 



876 



INDEX 



Suprarenal glands extract in Addison's 
disease, 469 
in adrenal insufficiency, 468 
in asthma, 469 
in burns, 468 

in depression following chloro- 
form and ether anesthesia, 
468 
in development of genitalia, 467 
in indigestion, 469 
in neurasthenia, 471 
in neuro- circulatory asthenia of 

enlisted men, 466 
in shock, 465, 466 
function, 458 
hypersecretion of, 461 
hyposecretion of, 463 
relation of tobacco to, 468 

to glycosuria, 459 
uses, 465 
sprays in hay fever, 470 

to control acute congestions in 
tonsils and pharynx, 471 
Suprarenalum siccum, 97, 471 
Suprarenin, 459 
Surface of body, simple disturbance of, 

treatment of, 776 
Sweat bath, 661 
Sweating of feet and axillse, 796 

profuse, strychnine in, 230 
Swedish system of physical culture, 683 
Sweet birch, oil of, 77, 376 

oil, 80 
Sylvester method of artificial respira- 
tion, 752 
Syncope, sudden, alcohol in, 242 
Synonyms, drug, 101-104 
Syphilis, arsphenamine in, 345 
calomel in, 345 
early diagnosis of, 344 
in male, prevention, 531 
in pregnancy, 346 
iodides in, 346 
liver disturbances during treatment 

of, 350 
luetin skin test in, 344 
mercury in, 345 
nephritis in, 347 
of brain and cord, 346 
prevention of, 343 
salvarsan in, 345 
thyroid gland in, 419 
treatment of, 343, 345 
Wassermann test for, 344, 549 
by lumbar puncture, 572 
Syringe, hypodermic, proper method 

of using, 534 
Syrup of acacia, 46 

of calcium lactophosphate, 353 

of citric acid, 47 

of ferrous iodide, 395 

of ipecac, 74 



Syrup of rhubarb, aromatic, 91 

of tolu, 55 

of wild cherry, 89 
Syrupi, definition, 24 
Syrups, definition, 24 
Syrupus acaciae, 46 

acidi citrici, 47 

calcii lactophosphatis, 353 

ferri iodidi, 395 

ipecacuanhae, 74 

pruni virginianae, 89 

rhei aromaticus, 91 

tolutanus, 55 
Systemic action, drugs used for, 107 

condition, relation of skin to, 776 
Systolic hypertension, causes, 236 

Table, anesthetist's, in operating 
room, 302 
of equivalents for prescription writ- 
ing, 29 
of liquids for prescription writing, 28 
of solids for prescription writing, 28 
Tachycardia of hyperthyroidism, digi- 
talis in, 224 
Talc, purified, 97 
Talcum purificatum, 97 
Tannic acid, 48 
action, 145 
administration, 143 
as antidote in poisoning, 143 
as astringent, 143 
as gargle, 144 
preparations, 144 
troches, 49 
Tannin, 48 

glycerite of, 49 
Tapeworms, 175 

anthelmintics for, 175 
treatment, 176 
Tapotement, 675 
Tar, oil of, rectified, 80 
Taraxin, 551 
Taraxy, 551 
Tartar, cream of, 86 

emetic, 52 
Tartaric acid, 49 
Tea, 603 

drinking habit, 216 
Teel oil, 81 

Teeth and tonsils, infected, removal of, 
before major operation, 287, 294 
in endocrine disturbances, 400, 
401 
Temperature, body, drugs used to 
lower, 109, 325 
effect of morphine on, 264 
in fever, point at which to combat, 

reduction of fever m, 327, 328, 329 
taking in fever, 332 
Tenia, 175 



INDEX 



8 77 



Tennis as exercise, 685 
Tepid sponging, 663 
Terpin hydrate, 97 

to decrease secretion of mucous 
membranes, 206 
Terpini hydras, 97 
Tesla current, 646 

Test, cutaneous, for protein idiosyn- 
crasy, 554 
intradermal for tuberculosis, 563 
Moro skin, for tuberculosis, 563 
Schick, in susceptibility to diph- 
theria, 566 
tuberculin, von Pirquet, 563 
Testicles, 489 
description, 489 

extracts of, administration, 492 
function, 489 
transplantation of, in castration, 490 

in impotency, 491 
uses, 491 
Tetanus antitoxin, 568 
prevention of, 568 
treatment of, 568 
Tetany, calcium in, 352 
due to alkalosis, 443 
idiopathic, due to insufficiency of 

parathyroid glands, 440, 442 
specific treatment of, 352 
Tethelin, 446 
Theine, 58, 214 
Theobromine sodio-salicylas, 98 

as diuretic, 190 
Therapeutic chart, 809 
classification of drugs, 105 
incompatibility, 36 
measures, 513 
principles, 17 
Thermometric equivalents, 806 
Thorium-x, 654 

Throat and nose, care of, before 
administration of anesthetic, 295 
hot moist applications to, 669 
Thromboplastins, 510 

solutions in hemorrhage, 371 
Thymectomy, effects of, 494 
Thymol, 98 

as anthelmintic, 179, 180 
iodide, 98 
Thymolis iodidum, 98 

as dusting powder, 127 
Thymus gland, 493 

condition of, before administra- 
tion of anesthetic, 294 
dangerously enlarged, #-ray 

treatment for, 499 
description, 493 
extirpation of, symptoms, 495 
extracts in Graves' disease, 500 

in rickets, 500 
function, 494 
hyposecretion of, in idiocy, 497 



Thymus gland, importance in early 

life of children, 404 
in insanity, 404 
pathology, 497 
relation to bone growth, 494, 496 

to development of genitalia, 
498 
surgical removal of, 499 
uses, 500 
Thyroid gland, 406 

ability to prevent poisoning, 408 

activities of, 411 

chemistry of, 412 

condition of, before administration 

of anesthetic, 293 
desiccated, 432 
disease, Goetsch's test in, 422 

tests in, 422, 423 
dried, 99 
enlarged, 408 

determination of, 418 

types, 410 
extract in asthma, 439 

in chlorosis, 435 

in cretinism, 433, 434 

in defective growth of children, 

433 
in digestive disturbances, 438 
in dry scaly skin, 434 
in eczema, 434 
in epileptic attacks, 438 
in headache, 434 
in hemorrhages, 439 
in increasing blood-pressure of 

age, 439 
in infantile obesity, 435 
in menopause, 436 
in myxedema, 437 
in nocturnal enuriesis, 436 
in obesity, 437 
in puberty disturbances, 435 
in toxemias of pregnancy, 437 
in sterility, 409 
to stimulate activity of skin, 

183 
functions of, 409 
hypersecretion of, 420 

causes, 423 

symptoms, 420 
hyposecretion of, 430 

in adiposis dolorosa, 436 

in amenorrhea, 436 

symptoms, 430 _ 

thyroid feeding in, 431 
in pregnancy, 407 
in syphilis, 419 
insufficiency, iodine in, 409 
iodine content of, 412 
normal function of, 407 
pathology, 415 
physiology, 406 
preparations, uses of, 433 



Sy8 



INDEX 



Thyroid gland, radium in treatment, 

428 
relation to pancreas, 407 

to sexual life of female, 479 
treatment, contraindications for, 

439 
ac-ray treatment of, 428 
Thyroideum siccum, 99, 432 
Thyro-oxy-indol, 413 
Thyrotoxicosis, 418 
Thyroxin, 413^ 43 2 
in Graves' disease, 425 
isolation of, 413 
physiologic activity of, 414 
Tinctura aconiti, 49 
benzoini, 56 
cantharidis, 61 
cinchonae, 63, 357 

composita, 63, 357 
colchici seminis, 64, 373 
digitalis, 67 
ferri chloridi, 395 
gelsemii, 258 
iodi, 73 

lavandulae composita, 79 
nucis vomica?, 78, 228 
opii, 82, 260 

camphorata, 260 
deodorati, 82, 260 
rhei aromatica, 91 
scillae,92 
strophanthi, 96 
veratri viridis, 99 
Tincturse, definition, 24 
Tincture, definition, 24 
Huxham's, 357 
of aconite, 49 
of benzoin, 56 

for inhalation, 515 
of cantharides, 61 
of cinchona, 63, 357 

compound, 357 
of colchicum seed, 373 
of digitalis, 67 
of ferric chloride, 395 
of gelsemium, 258 
of iodine, 73 

as antiseptic, 119 
of lavender, compound, 79 
of mix vomica, 78 
of opium, 82, 260 
camphorated, 260 
deodorized, 82 
of rhubarb, aromatic, 91 
of squill, 92 
of strophanthus, 96 
of veratrum viride, 99 
Tinea cruris, 791 

trichophytina, 790 
Tissue, destruction of, quinine and 
urea hydrochloride in, 368 
drugs used to destroy, 106 



Toadstool poisoning, 768 
Tobacco, action of, 727 

habit, 725 

over-action of, effect on heart, 729 
symptoms, 728, 729 

poisoning, acute, 727 
chronic, 727 

relation of, to suprarenals, 468 
Toe-nail, ingrowing, 797 
Tolerance, modifying action of drugs, 

42 
Tongue, care of, in anesthesia, 297 
Tonic, arsenic as, 388 

bitter, nux vomica as, 228 

prescription for colds, 205 
Tonsillectomy, choice of anesthesia in, 

290 
Tonsils and teeth, infected, removal of, 
before major operation, 287, 294 

cleansing of, in acute conditions, 521 

extirpation of, effects of, 403 
Torticollis, hot moist applications for, 

669 _ 
Toxemias, thyroid preparations for, 437 
Toxitabellae hydrargyri chloridi cor- 

rosivi, 71, 117, 340 
Tfagacanth lotion for chapped hands, 

784 
Transfusion of blood, 543 
dangers from, 544 
indications for, 546 
Lindeman's rules for, 545 
Transplantation of testicles in cas- 
tration, 490 
Trichloracetic acid, 49 
as escharotic, 138 
Trigeminal neuralgia, alcohol injections 

in, 242 
Trinitrophenol, 99 

as emollient, 130 
Trinitrotoluene poisoning, 741 
Trional, 96 

action, 281 

as hypnotic, 281 

description, 281 

habit, 282 

over-action, 281 

poisoning, treatment, 282 

uses, 282 
Triturates, definition, 25 
Trituratio elaterine, 67 
Triturationes, definition, 25 
Troches, of ammonium chloride, 52, 202 

of cubeb, 321 

of tannic acid, 49 
Trochisci acidi tannici, 48, 144 

ammonii chloride, 52, 202 

cubeba?, 66 

definitions, 25 
Troy system in prescription writing, 28 
Truths about drugs, 800 
Tryptophan, 581 



INDEX 



879 



Tuberculin injections, 562 

preparations, 561 

test von Pirquet, 563 

therapy, indications for, 562 
Tuberculosis, calcium in, 443 

climate for, 703, 705 

diet in, 624 

heliotherapy in, 636 

ichthyol in, 131 

intradermal tests for, 563 

Moro skin test for, 563 

pulmonary, morphin in, 269 

treatment of, 561 

von Pirquet tuberculin test for, 563 
Turkish baths, 660 
Turpentine enemas, 158 

oil of, 81 
rectified, 81 

spirits of, 81 

stupe, 135 
Twilight sleep, 319 

Typhoid fever, Brand treatment in, 666 
prevention of, 559 
salol in, 382 

twenty-four hour diet for, 620 
vaccination in, 559, 560 
Widal reaction for, 549 
Tyramine, 232, 581 

hydrochloride, 235, 472 
Tyrosine, 581 

Ultraviolet rays, 63.5 
Under-weight, 39 
Unguentum acidi borici, 47 
tannici, 48 

as astringent, 145 
belladonnae, 55 
chrysarobini, 63 
diachylon, 732 
hydrargyri, 71, 339 
ammoniati, 72, 340 
dilutum, 71, 339 
oxidi flavi, 72, 340 
iodi, 74, 390 
phenolis, 84, 120 
sulphuris, 97 
zinci oxidi, 99 
United States Pharmacopoeia, 21, 22 
valuable drugs and preparations 
of, 46 
Uranium poisoning, 731 
Uranium-x, 654 

Urea, amount excreted daily, 581 
hydrochloride and quinine injection 
to destroy tissue, 368 
Uremia, hydrotherapy contraindi- 
cated in, 660 
pilocarpine in, 185 
Uremic coma, 744 

convulsions, raw kidney extracts in, 

508 
neuralgias, opium in, 269 



Urethral injections, 529 

solutions for, 530 
Urethritis, salol in, 382 
Uric acid, daily excretion of, 586 

excretion, drugs to increase, 398 
phenylcinchoninic acid to in- 
crease, 398 
production of, 586 
Urine, acid, 582 

drugs used to cause, 107, 192 
treatment, 190 
albumin in, 189 
alkaline, drugs used to render, 107, 

190 
amount of, drugs used to increase, 
107, 188 
how diminished, 188 
how increased, 188 
color of, drugs which change, 44 
disinfection of, 113 
examination of, before administra- 
tion of anesthetic, 293 
in fever, 332 

passage of, after operation, 301 
Urotropin, 70 

as urinary antiseptic, 194 
Urticaria, 780 

giant, 780 
Uses and action of valuable drugs, 109 
Uterine fibroids, radium in, 655 
roentgen-ray in, 651 
hemorrhage, ergot in, 369 
ice for, 670 
Uterus, action of ergot on, 233, 234 
drugs used to contract, 108 
radium treatment of, symptoms 
following, 656 

Vaccination, 557 

development of protection after 

559 
endermal method, 558 
for boils, 563 
for carbuncles, 563 
in gonorrhea, 563 
in hay fever, 561 
in Neisserian disease, 563 
in paratyphoid fever, 559, 560 
in small-pox, 557 
in typhoid fever, 559, 560 
method, 558 

period of protection from, 559 
subcutaneous, 559 
Vaccines, 547, 555 
antirabic, 564 
autogenous, 556 
bacillus acnes, 556 
protective and curative, 557 
Vaginal douching, 532 

frequency, 532 

solutions for, 533, 799 

yeast in, 510, 799 



88o 



INDEX 



Vaginal irrigation, 532 
Vallet's mass, 69, 394 
Vasoconstrictors, 108, 231 
Vasodilators, 108, 235 
Vasomotor ataxia, 691 
_ ergot in, 235 
disturbances, relation to endocrine 
glands, 405 
whole pituitary gland extract for, 
456 
Vegetables, laxative, 615 
Vegetarian fad, 610 
Venereal diseases, prevention of, 
methods, 343 
infection, prevention, 530 
Venesection, 538 
after gassing, 749 
in infants, 539 
indications for, 539 
method of, 538 
Veratrum viride, 99 
action, 213 
administration, 213 
fluidextract of, 99 
over-action, 213 
tincture of, 99 
to depress heart, 213 
uses, 213 
Veronal, 271, 282 

habit, 283 
Veronal-sodium, 282 
Vibration, 675 
Vinegar of squill, 92 
Vinegars, definition, 23 
Vitamines, 582 

antineuritic, 583, 584 

in milk, 585 
antiscorbutic, 583 
fat-soluble, 583 
in cereals, 585 

secreted by mammary glands, 584 
water-soluble, 583 
Vitriol, blue, 66 

as escharotic, 139 
Vomiting and nausea, morphine in, 269 
counterirritants for, 137 
drugs used to cause, 106 
of jpregnancy, nutrient enema for, 605 
relation of corpus luteum of 

pregnancy to, 474, 477 
thyroid extract in, 437 
postoperative, care of, 299 
Von Pirquet tuberculin test, 563 
Walking as exercise, 685 
Walnuts, fat content of, 597 
War gas poisoning, 748 
Warm baths, effects of, 658, 659 
Warts, 795 

salicylic acid for, 377 
solutions of formaldehyde for, 116 
Wash, mouth, formula, 620 
Washed sulphur, 96 



Wassermann test for syphilis, 344, 549 
lumbar puncture in, 572 
in epilepsy, 347 
Water. _ See also Springs. 

alkaline, 709 

amount needed, 707 

arsenic, 709 

as aid to digestion, 707 

boiled, 602 

calcium, 709 

carbonated, 708 

cathartic, 708, 709 

definition, 23 

distilled, 602 

to prevent salt deposits, 707 

drinking, goiter from, 417 

hard, goiter from, 708 

hot, fomentations, 135 

in fever, 329 

iron, 709 

lithium, 709 

of cinnamon, 78 

peppermint, 80 

radium, dosage, 653 

treatment, special forms of, 671 

witch-hazel, 53 
Water-soluble vitamines, 583 
Waves, Hertz, 635 
Weed, Jamestown, 95 
Weight, computing dosage according 
to, 38 

for age and height, table of, 39 

of children, normal, 38 
Weights and measures in prescription 

writing, 26 
Weir Mitchell treatment, 690. See 

also Rest Cure. 
Wet cupping, 537 
Whiskey, alcohol content of, 596 
White arsenic, 53, 382 

petroleum jelly, 84 

precipitate, 72, 340 
Whooping-cough, inhalation formula 
for, 516 

prevention, 560 

treatment, 560 
Widal reaction for typhoid fever, 549 
Wild cherry, 89 
syrup of, 89 
Wintergreen, oil of, 77, 376 
Witch-hazel water, 53 
Wood alcohol, 238 
poisoning, 764 
symptoms, 765 
treatment, 765 

bitter, 89 

charcoal, 61 
Wool fat, 50 

hydrous, 50 
Worms, hook-, anthelmintics for, 179 

pin-, anthelmintics for, 178 

round-, anthelmintics for, 177 



INDEX 



88l 



Worms, tape-, anthelmintics for, 175 
Wormseed, American, oil of, 78 
oil as anthelmintic, 180 

for hook-worms, 179 

for round-worms, 178 
Wrist-drop from lead poisoning, 735 

Xeroform, 156 

Xerophthalmia, diet in, 631 

#-Ray, 649 

treatment for dangerously enlarged 
thymus gland, 499 
for metrorrhagia, 651 
for uterine fibroids, 651 
of ovaries in osteomalacia, 483 
of thyroid in Graves' disease, 427 

Xylol for pediculosis, 793 

Yeast as laxative, 615 
as stimulant to nutrition, 510 
for multiple boils, 788 
in intestinal putrefaction, 174 
in septicemia, 510 
solutions for vaginal douching, 510, 

799 
therapeutic value of, 510 



Yellow iodide of mercury, 71, 339 
description, 339 

mercuric oxide, 72 

mercurous iodide, 71 

Peruvian bark, 63, 357 
Yoghurt, 589 
Young practitioner, ethical suggestions 

to, 831 
Youth, exercises for, 685 

Zander methods of exercise, 683 
Zinc, 601 

carbonate, precipitated, 99 

chloride as escharotic, 140 

oxide, 99 
ointment, 99 

preparations as dusting powders, 
128 

stearate, 99 

sulphate, 100 
as emetic, 156 
Zinci carbonas praecipitatus, 99 

oxidum, 99 

stearas, 99 

sulphas, 100 



•v 



56 



tfA 






